'Is It a Boy or a Girl?' Intersex Children Reshape Medical Practice

Article excerpt

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Imagine for a moment that you are a family doctor, and you have just delivered the first-born child of a young couple. As the baby yelps its first cry of freedom and the nurse tends to the mother, you inspect the child's genitals to answer what you know will be the family's next question: "Is it a boy or a girl?" You hesitate and answer, "I can't tell."

As the doctor, you have delivered an intersexed child, a child with biologically male and female sexual features. Such children, born with ambiguous genitals, make up about one in every two thousand to four thousand births. What do you do now?

If this happened just a decade ago, the doctor would offer a relatively stock response. Doctors had been taught in medical school to make their decisions based on the length of the penis. The child is called a boy if it is longer than an inch. If shorter, the doctor typically recommended that the genitals be operated on to appear as a girl's. After designating the child a girl, regardless of its actual sex, doctors would tell the moms to raise the child as such.

A similar course was followed with children who were biologically female but born with a masculine-looking clitoris. Doctors typically recommended surgery to provide the "correct" female look. "Everything will be all right," the parents were told. Most doctors saw these procedures as simple and appropriate solutions. They might not even tell the parents of the procedures if the parents seemed unable to understand the complicated issues involved.

Most people believe that everyone is born as one of two "types," male or female. But the exception is far more common: More than one in every hundred newborns has an intersexed condition. Infants are born with many varieties of intersexuality, many of which are not signaled by ambiguous genitals. These infants look just like their brothers and sisters. Their situations may not become clear until puberty or adulthood. And for many, the precise intersex situation never becomes clear without genetic, anatomical, hormonal, or other tests.

Typically people have twenty-three pairs of chromosomes--bundles of DNA material--that determine sex and other traits. Most males pair a Y chromosome with an X chromosome. Females pair two X chromosomes. But some infants are born with extra sex chromosomes such as XXY or XXXYY. Intersexed children can be born with both one testis and one ovary. They can be born with the genitals of the opposite sex. Some children appear to be females at birth and then switch to look like males at puberty.

For reasons of privacy, this reality has rarely been discussed outside the context of medicine and biology. Physicians that treat children with intersex characteristics have found it easier to gloss over any biological discussion with the parents and concentrate on medical management. Until recently, the conventional approach had been set five decades ago when a Johns Hopkins University psychologist argued that humans were psychosexually neutral at birth, so it didn't matter whether infants were raised as boys or girls. That view was based on a study of how he interpreted people with "differences of sex development"--or DSD, the now-preferred term for intersex conditions--fared.

Although it was believed that an infant could adapt to either sex, three practices were encouraged to facilitate sex assignment. First, surgery was performed to correct any sexual ambiguity. Second, the child was not told of the ambiguity, surgery, or assignment of gender. Finally, the child was brought up consistently as whatever gender was assigned. Because it was easier to fashion a female-appearing set of genitals than a functioning penis, male infants were often reassigned as girls. Many thousands of people around the world have received such treatments, and genital surgeries on infants and children continue today.

I have studied this topic for many years and for a host of reasons believe that this approach is faulty and should be changed. …