Just-So Stories about Hermaphrodite Fish

A central issue that makes life hard for intersex people is invisibility.  Most people are unaware of how common intersex individuals are, something I’ve often discussed on this blog.  But there’s a larger setting in which the fact that sex is a spectrum gets erased, and that’s in descriptions of biology and the animal kingdom as a whole.  One way this happens is when biology textbooks fail to mention the fact that instances of intersexuality are found in all animals.  Another way it happens is through what we’re taught about those species in which hermaphroditism is the norm.  It’s the latter that I want to illustrate for you today, by examining about how we talk about a fish, the bluebanded goby. 

The bluebanded goby is a small and colorful fish, bright orange-red with iridescent blue stripes.  Bluebanded gobies are hermaphrodites, with the ability to produce either eggs or sperm.  Each bluebanded goby can switch from producing eggs to sperm or vice versa in the space of about two weeks; externally, there’s very little difference between an egg-laying or sperm-producing bluebanded goby.  They have a “sexual papilla” through which they can release egg or sperm, and it is a bit pointier when in sperm-producing mode and a bit wider in its opening when in egg-laying mode.   Most bluebanded gobies spend most of their lives in egg-laying mode.  They live in mating groups, and typically only one member of each group produces sperm, with the rest laying eggs, maximizing the number of offspring the mating group can produce.  It’s a neat arrangement.  It’s also not one that you’re likely to hear about if you are visiting an aquarium or keeping fish.

The intersex nature of the bluebanded goby is erased or distorted in most descriptions of the fish, because our society is so invested in the idea that sexual dyadism is natural and universal that we can’t see evidence to the contrary right in front of our eyes.  We don’t hear about it in our educations.  Say, for example, you’re a schoolchild going for an educational trip to an aquarium, and you see the pretty gobies there.  Here’s all you’d learn at the Cabrillo Aquarium in San Pedro, California about the sex of bluebanded gobies: “Recognized by an elongated robust body and two dorsal fins, males have longer dorsal spines and a suction-like disc that is formed by the connection of its pelvic fins.”  (See here.)  You’d hear yet another example of the “natural, universal fact” that all animals are male or female, not evidence of the sexual diversity of the natural world.  Not only does the hermaphroditism of the gobies go unmentioned, the “masculinity” of bluebanded gobies in sperm-producing mode is exaggerated—they are said to have “longer dorsal spines,” a phallic and aggressive description of a nonexistent difference.  In fact, scientists determining whether a bluebanded goby is in egglaying or sperm-productive mode do not look for any difference in dorsal spine length, only at the shape of the sexual papilla.  (Generally, a sperm-producing bluebanded goby will be on the large side for the species, and hence will have largish fins—but egglaying bluebanded gobies that are large have the same size dorsal spines, and the dorsal fins on a given fish do not change size when it moves between egglaying and sperm-producing modes.)

When popular educational sites do mention sex variance in the bluebanded goby, they don’t explain the fact that all bluebanded gobies are hermphrodites, capable of producing eggs or sperm.    They instead tell a story of rare and fascinating “sex changes” in fish that are otherwise binary in sex: “Males and females are similar in coloration, however, males have a longer dorsal fin than the females do. One interesting fact about blue-banded gobies is that if there is no male present, the dominant female in a group of blue-banded gobies has the ability to change her sex to that of a male.”  (See here.)  This description frames bluebanded gobies as sexually dyadic, existing as males and females, except for the occasional female who goes through a “sex change” in desperate times.  The fact that all of the bluebanded gobies are hermaphrodites, and that each time they move from group to group they have the ability to move from egglaying to sperm-producing mode or vice versa, goes unmentioned.  Rather than undermining the ideology of a natural sexual binary, the story of the rare “sex change” actually bolsters it.  “How bizarre and rare is this deviation, a one-time move between natural binary sexes!”

Not only do educational sites teach that bluebanded gobies are almost always “normal males and females” rather than always hermaphrodites, the way they present goby “sex changes” reflects ideas about human gender roles.  The BBC Science and Nature website states that bluebanded gobies “live in small groups with a single male and multiple females.  If the male leaves or dies, the largest female changes sex.”  (Link here.)  The story is one of a large, dominant male with his harem of smaller females, and a burly female fish changing sex to “rise” to male status and take over the harem.  This is how the story is told by most scientific articles about bluebanded gobies that’s I’ve seen.  Let me quote a passage from a 2005 article in the Biological Bulletin on “sex reversal” in bluebanded gobies, so we can examine this in more detail:

“Larger size often equates with increased success in aggressive encounters and therefore social dominance, providing a proximate mechanism for the size advantage hypothesis. In protogynous sex changers, the most reproductively significant resource that dominance affords is “maleness”; thus the reproductive payoff for dominance is extremely large, and females would be highly motivated to increase their aggressive behavior in times of social instability (i.e., in the absence of a dominant male).”  (See here.)

I’ll now restate that passage in clearer English and make overt its hidden assumptions: “Sex is binary but in some rare species ‘sex reversal’ can occur.  When it does occur, it is from female to male, because everyone knows it’s better to be male.  To be male is to be dominant and aggressive, which is good.  Usually in species where ‘sex reversal’ can occur, males keep the females in their place, but if there’s no male around, the females will all want to battle because the winner will get to be the male.”  This just-so story reaffirms all sorts of human gender stereotypes—and in so doing vastly distorts the objective reality of bluebanded goby life.

The first way the scientific fable distorts reality is by calling hermaphroditic gobies “males” and “females,” imposing binary sex language on fish that are born hermaphrodites and can shift back and forth between egglaying and sperm-producing modes multiple times in the course of their lives.  The term “sex reversal” also implies two opposite sexes rather than one sex continuum.  It would be much more reflective of objective reality to speak in terms of shifts in reproductive modes among hermaphrodites than about sex reversals between females and males.

The term “protogynous” used to describe gobies in the article means “starting out female,” which not only implies that the fish are not really intersex by nature, but also frames shifts in reproductive mode as only occurring in one direction: from “female” to “male.”  In fact, bluebanded gobies shift just as easily from sperm-producing to egg-laying modes when entering a group with multiple sperm-producing fish.  (See here.)  The idea that every bluebanded goby “wants to be the male” is a projection of human ideologies onto fish behavior.  The majority of bluebanded gobies at any given time are living in egglaying mode because this conveys a reproductive advantage for the group.  One could just as easily say that it’s obvious that most gobies “want to be female” since that’s what most of them do, but that one of them has to make the sacrifice and “be male” for the good of the group.  That would also be projecting emotions and motivations onto the fish, of course.  In fact, bluebanded gobies are just hermaphrodite fish reproducing in the most efficient way possible by operating in egglaying mode more often than sperm-producing mode.  But the story we read is one of enforced, devalued feminization and aspirational maleness, because that affirms sexist human gender ideologies.

Entwined with these male-privileging gender ideologies is a story about dominance and submission.  As the story goes, high status fish are dominant; low status fish are submissive.  The most aggressive and dominant bluebanded goby “gets to be the male,” while the rest have lower status that accords with their more timid female nature.  This narrative is so familiar in patriarchal society that scientists seem not to notice it’s an ideology they’re imposing on nature in their research and writing. 

Here is what we do know about bluebanded goby reproduction, stripped of human gender ideologies.  In this hermaphroditic species, the greatest number of offspring are produced when most of the fish are laying eggs.  So they form mating groups or families, typically of 3-7, in which one of the gobies’ bodies shifts to sperm-producing mode, and the rest shift to egg-laying mode.  The fish that takes on the inseminating mode needs to be robust, because it must continuously mate with the rest of the fish.  When mating groups form or change, the members all swim about actively, zipping toward one another.  (Actually, this behavior is quite common, and regularly occurs between all of the bluebanded gobies, including the egglaying ones in established groups.)  What determines which goby in a new group will take on the sperm-producing role is the behavior of the other fish.  A goby being zipped at by a zippier fish will dodge out of the way.  This gets called “submission” by scientists, but could just as well be termed “peacekeeping,” and would most accurately be simply called “getting out of the way.”  By engaging in this dance of zipping about, a new group of gobies determines which of the fish is the most energetic and robust.  Often it’s a large fish, but that’s not always the case.  That fish shifts to sperm-producing mode (unless it is already in that mode), and the others shift to egg-laying mode (unless that is already the case).

Oh, and by the way, bluebanded gobies that are in sperm-producing mode don’t “fight harder” to stay in that mode because they “don’t want to be female.”  If a group of bluebanded gobies is assembled completely out of fish that are in sperm-producing mode, all but one of them shift to egglaying mode.  This takes the same amount of time as it does for one sperm-producer to emerge from a group that is assembled out of gobies that are all in egglaying mode, and leads to the same rate of fertility.  (See here.) 

So: by nature, bluebanded gobies are intersex fish that form efficient mating groups of multiple egglayers and one inseminator, and shift reproductive modes as they move from group to group.  This is an interesting part of the wide diversity of sexual arrangements in nature.  I believe that teaching people about this natural diversity would make the world a better place for intersex people, as it would make it less likely for us to be perceived as “unnatural” and “disordered.”  But instead of teaching children about sexual diversity, educational sites either completely deny that bluebanded gobies are hermaphrodites, or only mention it as a story of rare and odd sex changes from dyadic female to dyadic male.  And scientists, educated like the rest of us in this context, impose all sorts of ideologies about binary gender roles onto what they observe about the fish, perpetuating the problem of distortion.

Nature is so much more interesting than the stories we tell ourselves about it.  It’s time to stop obscuring the objective fact of sexual diversity.

Images and Musings Available on Tumblr

Sometimes I run across images related to intersex matters that make me want to applaud, or to go hide under my bed.  I've decided to start sharing some of these pictures and my thoughts on them on Tumblr, so if that sort of thing interests you, feel free to visit The Intersex Roadshow Reports.

Trans and Intersex Children: Forced Sex Changes, Chemical Castration, and Self-Determination

Children’s lives lie at the center of social struggles over trans gender and intersex issues. If you talk with trans and intersex adults about the pain they’ve faced, the same issue comes up over and over again, from mirror-image perspectives: that of medical interventions into the sexed body of the child. Intersex and trans adults are often despairing over not having had a say as children over what their sexes should be, and how doctors should intervene. Meanwhile, transphobes and the mainstream backers of intersex “corrective” surgery also focus on medical intervention into children’s bodies. They frame interventions into the sexual characteristics of intersex children as heroic and interventions into the bodies of trans children as horrific.

The terms and claims that get tossed around in these debates are very dramatic. Mutilation. Suicide. Chemical castration. Forced sex changes.

We need to understand what’s going on here, because it’s the central ethical issue around which debates about intersex and trans bodies swirl. The issue here is the question of self-determination, of autonomy. Bodily autonomy is the shared rallying cry of trans and intersex activists, though we might employ it in opposite ways. Refusing it to us is framed as somehow in our best interests by our opponents.

In this post we will look at how four groups frame the issue: intersex people, trans people, the mainstream medical professionals who treat intersex people, and opponents of trans rights.

If you talk to people who were visibly sexvariant at birth, you hear a lot of pain and anger and regret about how their bodies were altered. This is crystallized in the phrase of intersex genital mutilation, or IGM. As a result of infant genital surgery, many intersex people suffer from absent or reduced sexual sensation—something mainstream Western medicine presents as unethical female genital mutilation (FGM) when similar surgeries are performed on girls in other societies. There are further sources of pain: as a result of “corrective” surgeries, intersex people can suffer a wide range of unhappy results, such as loss of potential fertility, lifelong problems with bladder infections, and/or growing up not to identify with the binary sex to which they were assigned. It is extremely painful to identify as female and to know one was born with a vagina that doctors removed with your parents’ consent, or to identify as male and to know one’s penis was amputated. Imagine if someone performed a forced change on you--would you not feel profoundly violated?

So the intersex perspective is that no one should medically intervene in a person’s body without that person’s full informed consent. Bodily autonomy is a fundamental right. Nobody except you can know how you will feel about your bodily form, whether you might want it medically altered, what risks of side-effects you’d consider acceptable. Routine “corrective” surgery performed on intersex infants is thus a great moral wrong.

When you speak with trans people, childhood medical intervention again comes up with an air of great regret, but now the regret is that one was not permitted to access it. Almost every person I’ve ever spoken with who wants to gender transition medically, whether they’re 18 or 75, has expressed the same fear to me: “I’m afraid I’m too old!” For a while this mystified me (how is 22 “old”?), until I realized what they meant was, “I’m post-pubertal.” For many trans people, childhood was awkward but tolerable, as children’s bodies are quite androgynous. Puberty, however, was an appalling experience. Secondary sexual characteristics distorted the body—humiliating breasts or facial hair sprouting, hips or shoulders broadening in ways no later hormone treatments could ever undo. Many trans people live with lifelong despair over how so much maltreatment and dysphoria could have been avoided if they could just have been permitted to avoid that undesired puberty.

So for trans activists, advocating for trans children so that they might avoid this tragedy is vitally important. The child’s autonomy is central, as it is for intersex advocates, but here the issue is getting access to medical treatment in the form of hormone suppressants, rather than fighting medical intervention. What trans activists seek is the right of children to ask for puberty-postponing drugs, to give the children’s families and therapists time to confirm that the children truly identify as trans, and fully understand what a medical transition involves. Then the individual can medically transition to have a body that looks much more similar to that of a cis person than can someone who has developed an unwanted set of secondary sex characteristics.

So for trans and intersex people, children’s autonomy is paramount when it comes to medical interventions into the sexed body. No child should have their sex (e.g. genitals, hormones, reproductive organs) medically altered until they are old enough to fully understand what is involved and actively ask for such intervention. Conversely, once a child is old enough to fully understand what is involved in medical interventions into the sexed body, and requests such intervention, then it should be performed—whether the child is born intersex or not.

This is not yet mainstream medical practice, however. Today, one in every 150 infants faces medical intervention into the sexed body to which they cannot object or consent. Doctors routinely perform such “corrective procedures” on babies with genital “defects” and “malformations.” Meanwhile, few trans-identified children are supported in their identities by families and medical practitioners—and great controversy and resistance swirls around them when it does happen.

So let’s look at the arguments made by mainstream medicine and transphobic activists. How do they counter the cry for autonomy, given that self-determination and freedom are such central ideals in Western societies? What we’ll see is that they employ two opposing claims based in medical ethics: the duty to save a life, and the duty to first do no harm. If we want to protect the rights of trans and intersex children, we have to understand these arguments and be able to counter them.

When intersex advocates try to fight the framing of intersex children’s bodies as “defective” and somehow in need of surgical “correction,” mainstream medicine responds with a claim of medical necessity. In some very rare cases, particular intersex conditions can be associated with actual functional problems such as an imperforate anus, clearly a serious medical problem that necessitates surgery. But the vast majority of medical interventions into intersexed bodies take place without any such functional, physical problem exsting. They are responses to a social issue (discomfort with sex variance) rather than a physical one. What doctors do, however, is reframe social issues into medical ones. “If we don’t do this surgery, this child will be mocked and humiliated—“he” won’t be able to stand to pee, “she” won’t be able to have “normal sex,” “it” will never be able to marry. The child will be a social pariah and thus be at risk for suicide.”

Through this line of argument, altering the body of the sexvariant infant is cast as a noble act that doctors perform out of their duty to save lives. To counter this, what we need to do is point out that actual studies of intersex adults show that while we do have a heightened risk of depression and suicide, these are caused by unhappiness with our medical treatment rather than prevented by it. Loss of sexual sensation, feelings of having been humiliated by doctors, pain from years of “repair” surgery after “repair” surgery, and for those who do not identify with the binary sex to which we were assigned, the vast sense of betrayal that those who were supposed to care for us subjected us to a forced sex change—these are what lead to an increased risk of suicide. What would really help is would be for doctors to follow the precept of “first do no harm,” to perform no procedures upon us without our full informed consent, and meanwhile, to provide intersex children and their families with social support.

Invocations of “primum non nocere,” first do no harm, and of despicable medical impositions on the lives of innocents are also raised by anti-trans advocates. Transphobic activists generally frame all medical transition interventions as mutilations, and this rhetoric rises to fever pitch when the issue of trans children arises. Recently, anti-trans rhetoric has framed the medical provision of puberty-postponing drugs as “chemical castration” (e.g. in this blog post).

“Chemical castration” is an odd concept. First off, if you read any medical article on the topic, you will find it starting by pointing out that the term is a misnomer, as none of the medications used in “chemical castration” destroy the gonads. The term is nevertheless employed due its specific history as a treatment being given by court order to “sexual deviants” to suppress their ability to have sex, where some prior courts had employed actual surgical castration. Today, some jurisdictions use “chemical castration” in cases of pedophilia, but it the past it was a treatment imposed on men convicted of sodomy—that is, to gay men in an era in which gay male sex was criminalized. Transphobic activists use the term “chemical castration” to evoke an aura of adult sexual deviance, in a manner calculated to frame doctors who provide puberty-suppressant drugs as sexually abusing children.

There is a curious twist in this matter of “chemical castration,” in that universally when court-ordered in the past, and often still today, it did not consist of testosterone suppression drugs as you would expect. Instead, injections of estrogen and/or progesterone were (and are) given. In essence, it caused a forced sex change. Thus, for example, when codebreaking British war hero Alan Turing was convicted of homosexuality in 1952 and sentenced to “chemical castration,” he found the unwanted sex changes in his body so horrifying and humiliating that he committed suicide two years into “treatment.”

In the case of trans-identified kids today, the use of the term “chemical castration” is thus a double misnomer. Firstly, no child is castrated—instead, puberty is simply postponed so that if the child, family, and therapist all agree later that a medical transition is appropriate, unwanted secondary sexual characteristics will not have developed. Plenty of adolescents are “late bloomers” by nature; in fact, puberty today occurs many years earlier than it did through most of human history, when human diets lacked sufficient fats and nutrients to support early puberties. So postponing puberty carries no significant dangers. Further, the point of hormone suppression is not to cause a sex change, in contrast to court-ordered “chemical castration treatments.” The point is merely to buy time to ensure that the trans child in question fully understands zir gender identity and the implications of medical transition.

So: we’ve seen a lot of charged language, of claims and counterclaims regarding mutilation versus vital treatment, cruel withholding of medical assistance versus the imposition of sex changes on unconsenting children. How should trans and intersex advocates respond?

What I would do is to point out that strange and conflicting ideas about children’s autonomy and free will are presented by our opponents. When specialists in intersex “corrective” treatments speak to parents or write in medical journals, they urge that genital surgery be performed in infancy, before age two and a half if at all possible. They claim that this way the child will not remember the treatment and will thus adjust well to the altered genitals and/or sex status. (As if medical monitoring and intervention did not often extend throughout the child’s life, and the procedures left no scars and caused no loss of sensation, so the child would “never notice.”) The age of two and a half came out of now largely-discredited ideas of a milestone of “gender constancy” occurring then, based upon notions of the developing brain that directly relate to autonomy. Before age 2.5, it was basically argued, the baby is irrational and lacks agency, and thus thinks magically about bodily sex, including accepting the “crazy” idea that the sex of the body can change. So, in urging very early intervention into intersex bodies today, conventional medicine is urging the total avoidance of the child’s rational thought and agency.

When it comes to treating trans children, on the other hand, instead of rushing things, all sorts of actors want to draw them out. Most doctors and clinics only provide transition services to legal adults. Those few who treat trans children are extremely cautious about providing any medical interventions other than the postponing of puberty.

Both of these approaches deny children autonomy over their bodies and their lives.

What we must urge is that society consistently respect the rights of children. No children should ever be subjected to sexual surgery without their consent. No children should be forced to have cosmetic surgery. But as children mature, they become able to consent to medical treatment that they do actively desire.

How old is “old enough” to agree to medical interventions into the sexed body? That answer depends on the given child—but 2.5 is certainly too young, and 18 is in most cases too old. What I suggest is that when addressing a medical practitioner urging genital surgery on an intersex infant, that we ask, “Would you perform a sex change on a child of this age who was not intersex?” Conversely, when facing transphobic activists saying that no one who is not a legal adult can be old enough to consent to medical transition services, we should ask if our opponent would say the same if the child were intersex. For example, a child with congenital adrenal hyperplasia may be born with a penis externally, and a uterus and ovaries internally. At around age 12 or 13, if there has been no medical intervention, that child can begin to menstruate through the penis, develop breasts, etc. Would the opponent argue that the child could not be old enough to say that he identifies as male and wants to take testosterone (or that she identifies as female and has decided that she wishes to have surgery to feminize her genitalia)? Would the opponent argue an intersex pubescent child should not at least be able to take puberty-postponing medications to avoid unwanted penile menstruation if they and their family and support professionals were still unsure whether to commit to any more permanent intervention?

What we must ask is that society treat intersex and trans-identified children consistently. We all raise our children to learn to make good decisions, so that they can lead good lives. We must nurture children’s autonomy as they grow, understanding that there are some decisions only they can make for themselves. To force a person to live in a sex with which they do not identify is cruelty; to impose unwanted bodily alterations unconscionable. Wishing happiness for our children, we must nurture and then defer to their right to self-determination over interventions into the sexed body.

How Common is Intersex Status?

If you poke around the internet trying to find out how common it is for a person to be intersex, you may well wind up frustrated that nobody seems to have a precise figure to give you. You'll probably encounter some commonly-cited odds: 1 in 2000, or 1 in 2500. People have passed these figures around for a number of years, until, by repetition, they've come to seem generally accepted. I used to repeat these figures myself, before I learned more about how they were generated. Being born intersex is presented as rare; less common, say, than being born with Down's syndrome.

These estimates are off by more than a factor of 10.

A true, conservative estimate is that more than 1 in 150 people are born with intersex bodies. In this post, I'm going to explain why the true commonplace of intersexuality is so widely underestimated. And yes, I'll justify my 1 in 150 estimate by the end.

There are two main reasons reasons why nobody can give you an exact figure for how many people are intersex. The first is that there is nobody gathering this data. And the second is that in trying to come up with an estimate, people rely on medical diagnostic categories that purposefully deny that many people with sexually-intermediate bodies are “really intersex.”

Let's begin with the matter of gathering data on who is intersex. A central problem we run into is that nobody is funding a cross-condition population study of sex variance. This is the case in part, ironically, because being intersex is perceived as a rare thing. In addition, being intersex is framed as a “treatable medical condition.” Thus, there's little sense of intersexuality being an urgent matter to prompt government or private entities to fund a large exploratory study. But even if a large study of all physical sex variance were to be funded, you'd run into problems with people not wanting to disclose their bodily statuses. Some intersex conditions are obvious at birth when children have visible genital variance. But these children are immediately assigned a dyadic sex, male or female, on their birth certificates. The children and their parents are told by doctors that they must conceal the childrens' “defect.” With both the medical profession and our society at large treating intersex status as something freakish and shameful, people who are born visibly intersex are usually extremely closeted about their status, and don't want to be studied, outed, exposed. They are unlikely to want to take part in studies.

Furthermore, many people are intersex without it being genitally obvious. Some people are chromosomally sex-variant: they have a genotype such as XYY or XXY that is not associated with a significant disability, or they are XY women or XX men. Such people may never find out that they are intersex—after all, have you ever had your sex chromosomes screened? Other people have variant internal reproductive organs. I, for example, had an ovotestis, a gonad intermediate between an ovary and a testis. I'd been told I had a supernumerary ovary after pelvic exploratory surgery, and it was only years later, after I'd had my internal reproductive organs removed, that a pathologist informed me it was actually an ovotestis. What this illustrates is that in order to do a mass study of the frequency of intersexuality, you can't just rely on interviews and on existing medical records. One would have to do extensive medical testing, including biopsies, of all the people studied, which would be very invasive.

Even if you were somehow able to get a large, representative, random subpopulation of people to agree to be genitally examined, hormone-screened, genotyped, CAT-scanned, and to have their gonads biopsied, the frequency of intersexuality would be drastically underestimated. And that is because of the second problem I mentioned: that of medical diagnostic categories.

Let's think commonsensically and rationally for a moment.

What does it mean to be intersex? Logically, it means that a person has a body that is intermediate between the idealized male and female poles of the sex spectrum. All of us start out in the womb with an intersex form, having a phalloclitoris, labioscrotum, and ovotestes (you can read more about this in this post). It's expected that these should differentiate as we develop, but in fact one or more elements of the sexual anatomy may stay fully intermediate, or may differentiate only partially. Any person who has a body that is not fully sex-differentiated is, logically speaking, intersex.

But medical diagnostic categories are not logical, despite our ideology that they should be so. The majority of individuals born with intermediate sexual anatomies are not given an intersex diagnosis. I believe that what underlies this is gender ideology. And that gender ideology is this: masculinity is fragile, especially when it comes to what a man has in his pants. To live as a man with an inadequate penis is seen as intolerable. To have one's status as a “real man” challenged is viewed as psychologically crushing. Thus, doctors feel, if they were to categorize someone as intersex and then assign them male, they would be acting cruelly. Women, on the other hand, are perceived as more gender-flexible. After all, it's reasoned, a woman isn't shamed by wearing pants or taking on a power career. Viewing female-assigned people as more comfortable with androgyny and as better at dealing with emotional challenges, doctors believe that if they diagnose someone as intersex, they should assign them to the female category.

Thus, under current the current regime of medical diagnosis and treatment, the large majority of people labeled by doctors as intersex are assigned female at birth. People who are diagnosed under the rubric of “female pseudohermaphrodites" (a ridiculous term devised in the 19^th century for intersex people with ovaries and intermediate genitalia or a phallus) are assigned female, and their phalli are surgically removed. People who are diagnosed under the rubric of “male pseudohermaphrodites,” with internal testes and genitals that are intermediate or vulvic, are also assigned female, and their testes removed.

Under this regime, most people—including academic gender scholars, doctors, and even a substantial number of intersex activists—believe that “almost all intersex people are assigned female at birth.”

You'll find this statement oft-repeated, but it's not true. At least as many babies with sex-variant bodies are assigned male at birth. It's just that the majority of them are not diagnosed as “true hermaphrodites” or “pseudohermaphrodites.” Many, for example, are characterized as “real boys” with a "urethral malformation." The diagnosis they receive is “hypospadias.”

Hypospadias occurs when a person develops testes, but the phalloclitoris is intermediate in form. People with hypospadias can fall anywhere on the sex spectrum from having fully intermediate genital configurations to having forms little different from what is considered typically male. (You can find illustrations midway down the page here.) In cases of what is termed “first degree hypospadias,” the person has close to idealized male anatomy, but the urethra opens on the underside of the penile glans. As the degree of hypospadias increases, the opening is lower on the phallic shaft, and is larger and more vulvic in form. In perineal hypospadias, there is a substantial vagina, the phalloclitoris is intermediate in structure, and the testes may be internal. And the bodily variance is not limited to the external genitalia. Hypospadias is associated with an enlarged prostatic utricle, which may vary from a slight enlargement with low degree hypospadias, to a full-sized uterus in high degree hypospadias.

Rationally speaking, people with hypospadias are intersex. They share with other intersex people not only sex-variant anatomy, but the common experience of imposed genital-normalizing surgery in childhood, and the unwanted consequences of loss of sensation, infections, scarring and fistulae. And while individuals with mild hypospadias appear to be almost as likely to identify with their assigned sex as individuals with typical phalli, those with advanced degrees of hypospadias are much more likely to suffer from gender dysphoria with their male assignment. For medicine not to acknowledge that hypospadias is an intersex condition seems not only nonsensical, but often cruel. It may be true that people born with hypospadias who identify as male don't want to be publicly labeled intersex, just as male-identified people don't often buy T-shirts that say “Ask me about my erectile dysfunction!” or “Just call me Cocktail Wiener.” But our cultural obsession with male-classified people having large erections and unquestionable male status should not dictate medical diagnostic categories.

Now, here comes the kicker.

According to the CDC, hypospadias occurs in the U.S. in one in 125 children labeled as “boys,” or 1 in 250 births. In other words, if we looked only at this one condition, the minimum rate of intersexuality is 1 in 250.

There are other intersex conditions that are not diagnosed as such, though they are medically treated in the same way as other intersex conditions. Consider “clitoromegaly” and “micropenis,” the diagnostic terms for people with a clitorophallus of intermediate size. A child born with clitoromegaly is assigned to the female category, and today in the U.S. is given “clitoral reduction” surgery in the same way that a child diagnosed as a “female pseudohermaphrodite” is altered. Children born with micropenis in the U.S. are classified as boys, and must often endure surgical and hormonal interventions (sometimes even what is officially termed infant sex reassignment to female status). Yet individuals with clitoromegaly and micropenis are often not diagnosed as “offically intersex.”

So let us just look at individuals born with genitally intermediate bodies who are assigned male at birth. Micropenis occurs in 0.6% of male-classified people, or 0.3% of the population. Hypospadias occurs in 0.8% of male-classified people, or 0.4% of the population. Just looking at these two conditions, 0.7% of the population is born sex-variant. In other words, translating to odds, 1 in 142 people has either hypospadias or micropenis. That's more than 1 in 150.

We now see what happens when we employ the rational rule of classifying anyone who is genitally, gonadally or chromosomally intermediate as intersex. We logically include people with hypospadias and micropenis in the intersex category instead of excluding all conditions in which infants are assigned male. Now, for the sake of argument, let's just accept at face value the assertion that all other intersex statuses are so rare that the chances of having any other variation in gonads, genitals or chromosomes is 1 in 2500. I consider this extremely unlikely, but we'll just go with it. In fact, for the sake of our argument let's accept the ridiculous assertion a medical student once made to me: that there have only been 7 “real hermaphrodites” ever encountered in all of recorded medical history. By this logic, the chance of having any other intersex variation is 1 in a billion, or to simplify, basically 0. But we're still left with a minimum of 1 in 142 individuals having an intersex body.

That puts being intersex about on par with the likelihood of having green eyes.

Personally, I believe the rate is much higher. I do think it's unlikely we'll ever come up with an unquestionable exact number of intersex people, even if we get study funding and widespread permission from study populations, and even if medical diagnostic categories cease to be so irrational. Sex is a spectrum, and any way we slice up a spectrum is arbitrary and open to debate. (I remember my mother and grandmother perpetually arguing over whether the color turquoise was “really blue” or “really green,” and one could have similar endless arguments over the point at which an intermediate phalloclitoris is sufficently large-headed to “count” as a penis or sufficiently small-headed to “count” as a clitoris.) But at a very conservative minimum, more than 1 in 150 people have sexually intermediate bodies.

So the next time someone tells you that intersexuality is extremely rare, tell them otherwise. The next time you see a book about pregnancy that talks about uncommon complications and rare infant differences but never mentions how often babies are born intersex, raise a fuss. If you hear the old saw that “all intersex people are assigned female at birth,” clear up that misunderstanding. Be aware and help make others aware that the problems facing intersex people are not sad rarities, but burdens faced by many (over 2 million in the U.S. alone). And if you yourself are intersex and living a life in closeted shame, I urge you to stop believing you must live your life isolated and alone. You have a lot of siblings out there.

On Sex/Gender Checkboxes

Day in and day out, sex and gender minorities are boxed in by being confronted with sex/gender checkboxes. This starts the moment we are born, when a binary sex must be checked on our birth certificates: “male” or “female.” For individuals who are born with visibly intersex bodies, this requirement causes a crisis. Families and doctors make hasty decisions about which box they'll force us into, and we have to live with the consequences all of our lives. Having checked off a binary “M” or “F,” those with authority over our infant bodies often feel that trying to reshape our bodies conform to the box they've picked is unavoidable. Thus, genital surgeries are routinely performed, despite the deep unhappiness so many intersex people voice about the results as adults. Great pain might be avoided if parents were allowed to acknowledge our physical truth on birth certificates which included an intersex checkbox, or if the gender marker requirement were simply removed.

For people who are trans gender, gender transitioning is made traumatic in large part due to the checkboxes we must face daily. Binary gender markers are everywhere: on our drivers' licenses and passports, on loan applications and job applications, and on websites everywhere (from Facebook to shopping sites to online radio stations). Once you've checked off one box, changing it is bureaucratically and legally difficult—and sometimes there's no way to change it at all. This leads to all sorts of hassles and embarrassment, as we're “outed” in odd contexts. Worse still, if the gender we're living in doesn't match the marker on our ID, we're subject to being banned from flying, arrested by bigoted police officers, and denied employment.

For folks who don't identify with a binary gender, the world of checkboxes constantly denies our very existence. We go institutionally unrecognized, with no way to even try to say “I am here!”

Sex and gender minorities have some protection in institutional settings that bar discrimination on the basis not only of sex, but of gender identity or expression. But often, such policies are adopted with no follow-through on what it really means for a university or company or city to protect gender identity and expression. Unaware of our needs, administrators think only of ensuring that trans people aren't being kicked out just for gender transitioning. While this is certainly important, there are many more needs that must be addressed. And central among these are that sex/gender checkboxes protect the rights of sex and gender minorities.

I have written a Best Practices guide that is under discussion at my university. It lays out a plan for rewriting sex/gender checkboxes that is meant to address the needs of intersex, trans gender, and gender variant people, in this case, in a university setting. There are some inevitable compromises in it between institutional desires for simplicity and brevity, and our desires as individuals to have our identities recognized in all of their fullness and uniqueness. But I wanted to share it here so that other people who are looking for a guideline to use in seeking to better the way institutions around them limit sex/gender choices would have something to start with. It doesn't address the problem of birth certificates, for example, since universities don't issue them. It does, however, address the question of how sex and gender and sexuality should be measured in research in some detail.

Please feel free to share and employ at will.

Best Practices for Identification of Sex/Gender

Compiled by Dr. Cary Gabriel Costello

I. Foundational Principles

Institutions which commit themselves to protecting against discrimination on the basis of sex and of gender identity or expression (GIE) must give individuals the right to self-identify their sex/gender.

Whenever data are gathered about sex/gender, the rights of GIE minorities (intersex individuals, trans men, trans women, and individuals with alternative gender identities) must be protected.

II. Definitions

“GIE minorities” include intersex individuals, trans gender individuals (trans men, trans women, and individuals with alternative gender identities), and people with variant gender expression.

Intersex Persons

While it is common to believe that sex is binary—that is, that all people are born either male or female—in fact, sexual characteristics exist as a spectrum. There is a great deal of variation in chromosomes (XX, XY, XXY, XYY, etc.), hormones (relative levels of estrogen, progesterone and testosterone), secondary sexual characteristics (breasts, hair distribution, etc.) genital configurations, and gonads (ovaries, ovotestes, testes). Intersex people are individuals whose sexual characteristics fall toward the middle of the spectrum. Approximately 1 in 150 people are intersexed according to medical diagnostic criteria. Most are very private about this status, though some are public about it.

Trans Gender Individuals

Individuals whose gender identity does not match the sex they were assigned at birth are deemed trans gender. A trans man was assigned female at birth but identifies as male; a trans woman was assigned male at birth but identifies as female; a genderqueer individual may identify as neither male nor female. Trans gender individuals often transition to their sex of identification, though they may do so in different ways. Some transition socially by changing name, pronoun, and dress. Others also take hormones (testosterone or estrogen/progesterone) to alter their bodies. In addition, some get surgery to change their chests or genitalia. Because surgery is quite expensive, may not be covered by insurance, and because it carries serious risks, many trans gender individuals in the U.S. do not seek or are unable to access surgical transition services.

Variant Gender Expression

People of any sex or gender may have an atypical gender presentation—male femininity, female masculinity, or androgyny.

III. Best Practices in Collecting Data about Sex/Gender

The best practices for collecting data about sex/gender depend on context. If collecting data about sex/gender serves no purpose for the individuals from whom it is collected, then eliminating the question is the best practice. If data are being gathered to protect the rights and well-being of individuals, then individuals should be given self-identification options that allow GIE minorities to self-identify. These options include a shorter form for ordinary uses, and longer forms to be employed in research contexts.

Eliminating Unnecessary Requirements for Individual Sex/Gender Identification

There are many institutional contexts in which people are routinely asked to identify their sex/gender based on common marketing practices or institutional tradition rather than an intent to protect the individuals from discrimination on the basis of their sex/gender. (For example, this is a common requirement in registering to use website services.) In this situation, the best practice is simply to eliminate the unnecessary requirement of declaring sex/gender.

Standard Best Practices Short Form for Sex/Gender Identifications

In contexts in which data is collected order to ensure equal treatment and respect for all, information about sex/gender should be collected in a manner that protects GIE minorities. The goal in implementing sex/gender categories for general data collection is to protect the rights of all people, whatever their physical sex status or gender identity, including intersex individuals, trans men and trans women, and individuals with alternative gender identities. Thus, the inappropriate single question (“Sex: Male__, Female__”) should be replaced with a three-stage approach.

1. Gender identity: Woman __, Man __, Alternate Self-identification (please write in) ______________.
2. Do you have an intersex condition (disorder of sex development)? Yes__, No__.
3. Are you trans gender? Yes__, No__.

In order also to ensure nondiscrimination on the basis of sexual orientation, best practices add a fourth question unrelated to GIE:

4. Sexual orientation: Heterosexual __, Lesbian__,  Gay__, Bisexual__, Queer__, Pansexual__, Asexual__, Alternate Self-identification (please write in) ______________.

AVOID poor practices which undermine individuals' identities instead of protecting them. A common poor practice is to use a single additional checkbox: “Male__, Female__, Transgender___.” This is inappropriate for several reasons. First, it does not allow intersex individuals a way to identify themselves. Secondly, it discriminates against trans men and trans women by framing trans gender identification as incompatible with “real” male or female status. And thirdly, it does not allow for recognition of the distinct needs and identities of individuals who identify as neither male nor female.

Best Practices Long Forms for Research Contexts

Data about sex and gender are often collected in the course of research. If data are to be analyzed along the dimensions of sex and/or gender, two sets of needs must be met. The first relate to the rights of research subjects, who must be protected from harm, including the harm of discrimination on the bases of sex, gender identity or gender expression. In conducting research with human subjects, researchers will inevitably recruit research subjects who are intersex, trans gender, or variant in their gender expression, and are ethically obliged to treat them with respect. The second issue relates to the need of the researcher to have research questions carefully worded in a manner that subjects will understand and respond to in a reliable and valid manner.

Many scientific studies today continue to use “sex” as an independent variable, and measure this in a binary fashion. This is a methodological flaw, as well as discriminating against GIE minorities. It does not allow the researcher to measure what actually accounts for observed variance in the dependent variable: is it physical sex status, internal gender identity, gender-conformity or nonconformity? Just as a study that uses religion as an independent variable is improved when it not only identifies subjects as “Christian,” but allows the subjects to identify a more specific denomination, asks them how religiously observant they consider themselves, and inquires as to how often they attend church, increasing the sophistication of sex/gender questions improves study results.  The following measures are suggested:

1. What gender do you identify with? Man__, Woman__, Other (please write in the identity)________________.
2. What sex category were assigned at birth? Male__, Female__.
3. As far as you know, were you born with an intersex or sex variant body? Yes__, No__.
4. Please indicate how masculine or feminine you are in your dress and manner on the following scale: (1) very masculine, (2) moderately masculine, (3) a bit masculine, (4) androgynous, (5) a bit feminine, (6) moderately feminine, (7) very feminine.

In order also to ensure the study is not discriminating on the basis of sexual orientation, and to gather better data, best practices suggest that subjects also be surveyed on their sexual identity. Problems are often raised by the traditional method of asking subjects if they are “heterosexual, homosexual, or bisexual.” For example, people who are gender transitioning or who identify as neither male nor female are often unable to use these sexual orientation categories to classify themselves. Furthermore, it is well established that there is a difference between how many people identify their sexual orientation and the sexual activities in which they actually engage. This may be addressed through questions such as the following:

1. To whom are you attracted, sexually and romantically? (1) only men, (2) mostly men, (3) a bit more toward men than toward women, (4) equally toward men and women, (5) a bit toward women than men, (6) mostly women, (7) only women.
2. With whom have you been sexually involved? (1) only men, (2) mostly men, (3) a bit more men than women, (4) equally men and women, (5) a bit women than men, (6) mostly women, (7) only women.
3. Are the people to whom you are attracted (1) very masculine, (2) moderately masculine, (3) a bit masculine, (4) androgynous, (5) a bit feminine, (6) moderately feminine, (7) very feminine.
4. Consider the idea of a partner who identifies as neither male nor female, but as some other gender such as “genderqueer.” Do you find that (1) very appealing, (2) moderately appealing, (3) a bit appealing, (4) I feel neutral about it, (5) a bit unappealing, (6) moderately unappealing, (7) very unappealing.

Researchers who choose specifically to study GIE minorities should consider them a vulnerable subject pool for IRB human subject protection purposes. In cases of studies recruiting intersex, trans gender, or gender-variant subjects, procedures should be set in place to protect these vulnerable subjects, and the questions asked about sex and gender carefully designed to accord all subjects with full respect for persons. Confidentiality should be strictly protected, data collected in a location where subjects will not be at risk of having others see or overhear their responses, and information sheets listing appropriate support groups and links to mental health resources distributed to those recruited to participate.

Intersex Fertility

My daughter was not of woman born. That is a concept that has fascinated people through the ages.

My daughter's gestation was perfectly “natural,” I should point out--but I carried her, and I was never of the female sex; I am diagnosed as "true gonadal intersex.” I was assigned female at birth, and was living as such when I gave birth to her, but I never identified as a woman, and am now legally male.

A lot of myths circulate around the topic of intersex fertility, many of them perpetuated by doctors. They all relate to the current Western insistence on the ideology of sex dyadism. That ideology holds that there are two and only two sexes, and that this is required by “nature” in order to perpetuate the human species. In fact, sex is a spectrum (see here and here for more information). About one in 150 people has some intersex characteristic. However, in contemporary Western society we are hidden away, medically “corrected,” erased. And often this erasure is bound up in rhetoric about fertility.

One way in which medical textbooks frame intersex people as “tragic” is by presenting us as usually infertile. I'm not going to spend time critiquing the idea that a person must procreate to be a fully mature and valid adult, though I certainly don't believe that to be true. What I want to address from an intersex perspective is the fact that many of us are capable of reproducing. In fact, doctors often take surgical steps to “normalize” our bodies that render us infertile. For example, children born with external testes but absent or very small phalli are often surgically assigned female. The removal of their testes of course renders them infertile. Doctors frame these children as being born “incapable of reproduction” because of their small or absent penises, but this is laughable. Deep penetration is not necessary for pregnancy to occur via intercourse. Size really is irrelevant to the delivery of sperm. In fact, the availability of in vitro fertilization means that intercourse itself is unnecessary. What doctors are doing is conflating having a large phallus with fertility and with male identity. It's magical thinking—but it is used by supposedly rational scientists to justify surgical castration of children with variant genitalia.

In framing intersex individuals as usually infertile, doctors present procreation by intersex people as a medical curiosity, justifying the publication of medical journal articles about a “case.” And they frame facilitating such a procreative act as a sort of “medical miracle,” in which the doctor treating the patient is the hero. Wishing to be seen in such a light, doctors wind up putting a lot of pressure on those of us whom they know to be intersex and potentially fertile to reproduce. This sort of external pressure is uncomfortable and almost coercive, as I myself experienced. I was told by doctors that my fertility would probably decline over time, that my atypical uterus would probably eventually “have to come out,” and I was regularly urged not to postpone trying to have a baby. Though I love my kid immensely, I see the pressure that was put on me to conceive as unethical. My road to parenthood was painful, involving a series of miscarriages, a difficult pregnancy, and a labor, with my atypical uterus, that lasted 53 hours and left me with injuries that took several years to fully heal.

In facilitating an intersex conception or gestation, doctors frame themselves as heroic in two ways. First, they are heros for making this new life possible (as if they were the ones doing the procreating). Doctors present themselves in this way in all sorts of infertility treatments, not just in the case of intersex patients. But the second heroic framing is unique: the prior doctors who chose a dyadic sex for the intersex person are presented as having done a brilliant thing. Doctors treat a successful fertilization as validating the intersex person's sex assignment. If an intersex person assigned female becomes pregnant (or an intersex person assigned male successfully inseminates), then doctors presume they made the “right choice” in the sex assignment. Thus, if an intersex patient expresses unhappiness with their sex of assignment, doctors may put even more pressure on them to procreate. Unhappiness with one's assigned sex implies a critique of the medical professionals who made it, which makes many doctors uncomfortable. Rather than questioning the practice of surgical sex assignment in infancy, doctors want the critique to go away.

This pressure placed on unhappy intersex individuals to procreate in order to validate the medical sex assignment that is causing the person unhappiness is unfair—and also bizarre. It follows the pattern of medically assessing a “correct assignment” through sexual activity. If a person is assigned female, then all is well if they are able to “accept a penis” in vaginal intercourse—and if they can actually become pregnant through this, hark—the herald angels sing the savior doctors' praises. As someone who was assigned female and did eventually have a successful pregnancy, I can tell you that this assumption did not work for me. For me, as for many, what mattered most in my sex assignment is gender identity. I did not identify as female, and thus I was uncomfortable in my assigned sex. Experiencing a pregnancy did not relieve my discomfort. Carrying a child did not “cure” my gender dysphoria with my assigned sex. It didn't make me “feel like a real woman.” It just made me feel pregnant.

I'm glad that I was able to become a parent, but believing that this should have “cured” me of my distress with my assignment is magical thinking along the lines of believing that procreating will “cure” a lesbian or gay man and make them heterosexual. Gender identity, sexual orientation, and procreative status are independent characteristics. Lesbians and trans men and intersex individuals aren't mystically “converted” by pregnancies. Gay men and trans women and intersex individuals who inseminate someone aren't thereby made straight or cis or dyadically-male-sexed.

Sometimes intersex people assigned to the female sex inseminate a partner, or male-assigned intersex people become pregnant. In the first half of the 20^th century, when intersex children were rarely if ever surgically sex assigned, and doctors wrote about “cases of hermaphroditism” they encountered as adults, this was a popular topic in medical journal articles, but such is not the case today. Since there is no reason why intersex people should be born with less capacity for fertility that in the past, there are two possible explanations. Either medical interventions are rendering more intersex individuals infertile, or doctors have no incentive to publish about what they would deem “sex assignment failure.” A person a doctor has assigned female is not “supposed” to impregnate anyone, thereby supposedly providing embarrassing proof they should have been assigned male. The idea that someone might actually be happy with a female sex assignment and also pleased to be able to contribute to the conception of a child by providing sperm in the way their body permits does not enter the picture at all. The dyadic gender ideology doctors impose awkwardly onto intersex people is again revealed.

I believe that the framing of sex as dyadic also contributes to the everpresent popular question about fertility and “hermaphrodites”: can we impregnate ourselves? The answer is that it is extraordinarily unlikely, but I believe the reason this tired old query nevertheless comes up again and again is due to how people, having no idea at all of what intersex bodies are actually like, have to use their imaginations. Given the dyadic sex ideology, they figure that if a “hermphrodite” is both male and female, they must have both sets of “organs,” meaning a penis and vagina and testes and uterus and ovaries. Truly, if you ever want to despair of the level of ignorance about intersex bodies, just do an internet search for “hermaphrodite impregnate”. . . I find it hard to decide whether to laugh or cry reading people's musings on this topic.

But I can't really blame people on the street for the depth of their ignorance. People don't know about intersex bodies and experiences because we are hidden from them. Our sex status is erased by the legal requirement that we be declared male or female at birth. Our bodies are redacted by doctors trying to remove the evidence of our physical “deviance.” Information about intersex statuses is not taught in high school biology classes. The fact that sex variation is so common is a fact kept, for some reason, secret. And the large majority of intersex people are well-schooled to keep our “disorders” in the closet.

So I'm less bothered by the tediously-repeated “if you're a hermaphrodite, could you get yourself pregnant” question than I am by magical thinking on the part of medical practitioners. Intersex people are not tragic figures due to infertility. Some of us don't want children, and some of us adopt. Some of us do indeed produce children ourselves. We've done this throughout all of human history, not just recently due to medical miracles. Many of us who do reap the rewards of fertility do this in private, with no medical journal articles trumpeting a star in the east. In fact, some medical “corrections” of our physical differences render us infertile, and I don't see why that's treated as unimportant when doctors are so very willing to write articles about their “cases” who do prove fertile. And the magical thinking behind the idea that doctors can validate a sex assignment through the intersex person contributing the “correct” component, egg or sperm, to a conception just boggles my mind.

It's time for some more sophisticated thinking about intersex fertility.

A Companion Blog: TransFusion

As an intersex person who gender transitioned to male, I think about both intersex and trans issues a lot. The Intersex Roadshow is a blog focused on issues central to the live of people with sex variant bodies, and I only post information and thoughts on trans issues here that center on intersex experience. Recently, however, I started up another sibling blog to focus on trans issues. It's called TransFusion, and you can find it here: http://trans-fusion.blogspot.com/.

I have written two prior posts on The Intersex Roadshow that discuss intersections between intersex and trans gender experience. You can find them here and here if you are interested.

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.