When babies are born their anatomy dictates the gender according to which they are classified: a penis and testicles results in a male gender, a vulva and lips, or labia, equals female. It is a very binary approach which leaves little or no room for variation.
On the whole, we know that XY chromosomes make boys and XX chromosomes make girls. We also know that there is some variation to this rule, as some babies who are assigned male at birth turn out to be girls, and vice versa.
So what happens in the event that the genitals of the baby being gendered are ambiguous? In some cases it is not so obvious and parents and doctors struggle to work out the gender of the baby based solely on their anatomy. There are many complex medical reasons for this, and if we look back over history we can see outcomes for those children for whom the wrong gender is assigned.
We now know that we shouldn’t force any child to conform to a stereotypical picture of gender, merely on the basis of their body parts, but that we should instead, allow someone’s identity to develop naturally. That child will tell you soon enough whether they feel male, female, neither or both.
Here is a first hand account from one of our patients:
Growing up between the cracks
Between one and two percent of the global population are born with an Intersex condition: the I in LGBTQI+. Few people know of their existence or are aware of what being intersex means, even within the LGBTQI+ community.
An intersex person, historically referred to as a hermaphrodite, is someone who has some or all of the primary sex characteristics of both genders. According to a Health 24 definition there are three variations for those born intersex: true, male pseudo and female pseudo, though an intersex person may well have more than one variation.
Indeed, in the UK, some 40+ conditions meet this classification. These may be chromosomal, gonadal, anatomical and/or hormonal variations. The terminology used to diagnose the condition has evolved to become known as ‘Variations in Sexual Characteristic’. This language more accurately reflects the different characteristics that might result in an intersex diagnosis. Many characteristics may never be visible to the naked eye and others may not show up until later in life.
Today the term hermaphrodite is not only considered imprecise but to many intersex individuals it is considered derisory. Many intersex people wish to stay below the social radar but desire to be recognised medically as having an intersex condition/s.
Throughout the world, intersex conditions are currently termed Disorders of Sexual Development and are said to incorporate up to 1.7% of the population, in practical terms similar to the number of people who have green eyes or red hair.
It is one area where sex and gender become totally blurred and many are happy to continue to live in the gender they were assigned at birth. They wish to be accepted as being on a spectrum of physiological and psychological sex. Many intersex people have lived and died without ever knowing they had intersex characteristics. In practice, many are non-binary and refuse to be classified as either male or female.
Variations can include being genetically male but presenting outwardly as 100% female. Others grow to puberty as a girl, then develop a penis to be fully male. In the Dominican Republic, where there is a high prevalence of such individuals, this is often referred to as ‘guevedoces’ – which literally translates as ‘penis at 12’ and affects 8-10% of the female births. This is a similar frequency to those born with blue eyes here. Just think, every blue-eyed person you see represents a girl who becomes male at puberty in these societies!
In addition to XX (female) or XY (male), there can be multiple chromosomal permutations of the X and Y, such as XXY, XXXY, XYY and many others.
Many Intersex children born with ambiguous genitalia are operated on as infants. The decision on their sex historically having been made unilaterally by doctors based on the probable surgical success for external genitalia alone. While awareness is growing, medical intervention is often still the only choice given and it is one which, if parents are consulted, they are encouraged to make a decision on their child’s gender, shortly after birth.
As an intersex person myself, I feel we need to demand that such births be universally accepted and certified as Intersex. Individuals with these characteristics should be allowed to make an informed decision as late as early adulthood when their body, gender and personality have further developed. Without intersex being widely accepted, children will continue to grow up with the stigma and abuse I did. I was born with ambiguous genitalia and a body that produced competing levels of sex hormones, yet predominantly female. I was born intersex at a time when such conditions were shrouded in total secrecy.
In fact, it is only within the last six years that much of my own intersex spectrum has become known to me. I learned quite young that I’d had corrective surgery as a baby, but for most of my life I believed it was solely to correct my cleft lip and palate.
So I entered school as a boy (while my mother still treated me as a girl in the home.) It was only after being bullied at school for wearing knickers at age seven, I pleaded with her to buy me tidy whities!
I did not have a defined puberty, something which I considered a blessing at the time, as I made it through my early teenage years without a squeaky voice or acne! It only really became an inconvenience in early adulthood.
My mother spent a great deal of time in hospital from when I was nine until she died shortly after my twelfth birthday. Thankfully between five and eight years old she had taught me to cook, bake and look after the house. My father was out from the early hours until dusk working each day from when I was about nine years old, so I raised myself.
Having no one to observe my physical development and lack of virility as a teen, it was never noticed. Later my incomplete male puberty led to social and relationship problems. I sought solace in drink and recreational drugs. After a serious health scare, an endocrine test discovered that I had very low male hormones and normal levels of female hormones for a woman my age. My then male GP, told me I was hypogonadal and in very early andropause, the male equivalent of menopause in females. He immediately put me on supplemental testosterone without referral to an endocrinologist.
Later, under the care of an endocrinologist, this diagnosis was refined to hypogonatropic hypogonadism. A problem in the pituitary gland that reduces or stops precursor hormones which stimulate testosterone and oestrogen/progesterone production in the gonads.
Choices made for me shortly after my birth, combined with society’s straightjacket of binary sex/genders, meant everything throughout most of my life had been focused on affirming that early choice of male gender assignment by my mother. This sometimes led to medical idiosyncrasies being missed or misdiagnosed as some of these conditions are rare in males.
My first endocrinologist could not understand why, since I’d lived as long as I had as a male, I would want to change. She ignored the fact testosterone had been slowly poisoning me and my endocrine system was 99.9% female. My need to be a woman didn’t seem to have any relevance. Everyone tried to convince me MALE was a better way to go! A urologist treating me at that time suggested I allow him to surgically correct some of my genitourinary problems so I could recommence my injections. I was told by the urologist that I was too young to stop testosterone.
As time passed, my testosterone injections had become more and more frequent. My blood testosterone levels were high yet showed little positive physical effect. Six years ago, having been finally referred to an endocrinologist, I had my first diagnosis of an Intersex condition, P.A.I.S. (Partial Androgen Insensitivity Syndrome). Even when testosterone was present in my body, many hormone receptors in my body tissue didn’t respond or adapt and remained in their default female state. It was the first time I had any explanation for my delayed and incomplete male puberty. Various specialised tests since, have led to discovering additional variations in sexual characteristics.
Stopping the testosterone injections forced me into natural female feminisation and severe gender dysphoria. My body immediately began female puberty! I still didn’t know I had a number of intersex conditions at this point and being over 60 I didn’t want to upset my whole life without being sure that I was definitely transgender, so I contacted GenderGP. Therapy with them aided me to find my true self and reach female maturity. Most of my limited virilisation reverted to mainly feminine characteristics as I followed on with treatment under the care of my local Gender Identity Clinic (GIC) and their endocrinologist.
Eventually after a few years of Real Life Experience (RLE), and gatekeeping by the GIC, I underwent corrective surgery on 26th June 2019. A lifetime of being stuck between genders was finally addressed. The result of childhood genital surgery was reversed, re-aligning my body to its dominant physiological and psychological gender. I’d survived almost two decades of supplemental testosterone in an attempt to make my body conform to the sex my mother and her GP had chosen for me. He was a family friend who had delivered me as a home birth five weeks premature. Five years after commencing my transition journey, the final pieces of my physical gender were corrected in a gorgeous little hospital on the outskirts of Brighton.
That day at 10:18 I left my room for the walk to anaesthesia. Some minutes later I was on my back on a gurney and two cannulas were fitted into my left arm and hand. Once complete, the anaesthetist injected the contents of a syringe in through one of them and asked me if I felt it working. “Oh yes“ I exclaimed! I immediately felt a warm cocoon envelop me as I slipped into oblivion.
My next conscious memory was coming round in Recovery, I looked up at the clock, 11:53, only an hour and thirty-five minutes since I left my room. I burst into tears. The lovely Recovery nurse tried to console me and asked what was wrong. “Why did they stop my surgery, it’s only 95 minutes since I left my room?” “You’re alright, everything is fine, surgery is complete.” “I can’t have been in the OR for little more than an hour,” I exclaimed, tears still streaming. “You have no need to worry, surgery was a success and you’ll be back in your room soon,” she comforted me.
She was right, as I later confirmed from my surgical notes. I’d been in theatre for 63 minutes. I had been transferred from anaesthesia to the operating room, my corrective surgery completed, drains and packing inserted and dressings applied then wheeled to Recovery. All of that in a couple of minutes over an hour! My wonderful surgeon had done everything he said could take between two to two and a half hours. Finally, I was the woman I had always been.
In the intervening twelve months my endocrine results have shown that in addition to casting off any remaining male vestiges, I lost a very feminine part of me. By removing both gonads, the surgeon had removed an ovotestis that had been producing most of my oestrogen. Now my oestradiol levels are less than a third of what they had been before surgery, even though I’m still on the same level of oestrogen supplementation. No longer between the cracks, I am physically a single gender and finally very happy to be a woman.
I have succeeded so far in having my sex corrected on practically all aspects associated with my identity: passport, medical card, bank/credit cards and driving license. My struggle continues to convert my Interim Gender Recognition Certificate to a full certificate and amend the marker on my birth certificate to read Female. Deo volente, it will be completed before the end of 2020!