![Third International Intersex Forum](https://upload.wikimedia.org/wikipedia/commons/5/55/Third_International_Intersex_Forum.jpg)
Intersex people are individuals born with any of several
sex characteristics
Sexual characteristics are physical traits of an organism (typically of a sexually dimorphic organism) which are indicative of its biological sex. These can include sex organs used for reproduction and secondary sex characteristics which disting ...
including
chromosome
A chromosome is a long DNA molecule with part or all of the genetic material of an organism. In most chromosomes the very long thin DNA fibers are coated with packaging proteins; in eukaryotic cells the most important of these proteins are ...
patterns,
gonads, or
genital
A sex organ (or reproductive organ) is any part of an animal or plant that is involved in sexual reproduction. The reproductive organs together constitute the reproductive system. In animals, the testis in the male, and the ovary in the female, a ...
s that, according to the
, "do not fit typical binary notions of male or female bodies".
Sex assignment at birth usually aligns with a child's anatomical sex and
phenotype
In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology or physical form and structure, its developmental processes, its biochemical and physiological pr ...
. The number of births with ambiguous genitals is in the range of 1:2000–1:4500 (0.022%–0.05%).
Other conditions involve atypical chromosomes, gonads, or hormones.
Some persons may be assigned and raised as a girl or boy but then identify with another gender later in life, while most continue to identify with their assigned sex. The number of births where the baby is intersex has been reported differently depending on who reports and which definition of intersex is used. Anne Fausto-Sterling and her co-authors suggest that the prevalence of "nondimorphic sexual development" might be as high as 1.7%. A study published by Leonard Sax
Leonard Sax is an American psychologist and a practicing family physician. He is best known as the author of three books for parents: ''Boys Adrift'', ''Girls on the Edge'', and ''Why Gender Matters''. According to his web site, he is currently ...
reports that this figure includes conditions such as Klinefelter syndrome
Klinefelter syndrome (KS), also known as 47,XXY, is an aneuploid genetic condition where a male has an additional copy of the X chromosome. The primary features are infertility and small, poorly functioning testicles. Usually, symptoms are sub ...
(XXY) which most clinicians do not recognize as intersex, and that if the term is understood to mean only "conditions in which chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype is not classifiable as either male or female", the prevalence of intersex is about 0.018%.
Terms used to describe intersex people are contested, and change over time and place. Intersex people were previously referred to as " hermaphrodites" or "congenital eunuch
A eunuch ( ) is a male who has been castrated. Throughout history, castration often served a specific social function.
The earliest records for intentional castration to produce eunuchs are from the Sumerian city of Lagash in the 2nd millenni ...
s". In the 19th and 20th centuries, some medical experts devised new nomenclature
Nomenclature (, ) is a system of names or terms, or the rules for forming these terms in a particular field of arts or sciences. The principles of naming vary from the relatively informal conventions of everyday speech to the internationally ag ...
in an attempt to classify the characteristics that they had observed, the first attempt to create a taxonomic classification system of intersex conditions. Intersex people were categorized as either having "true hermaphroditism
True hermaphroditism, sometimes referred to as ovotesticular syndrome, is an intersex condition in which an individual is born with both ovarian and testicular tissue. Commonly, one or both gonads is an ovotestis containing both types of tis ...
", "female pseudohermaphroditism
Pseudohermaphroditism is a condition in which an individual has a matching chromosomal and gonadal tissue (ovary or testis) sex, but mismatching external genitalia.
Female pseudohermaphroditism refers to an individual with ovaries and external gen ...
", or "male pseudohermaphroditism". These terms are no longer used, and terms including the word "hermaphrodite" are considered to be misleading, stigmatizing, and scientifically specious in reference to humans. In biology, the term "hermaphrodite" is used to describe an organism that can produce both male and female gamete
A gamete (; , ultimately ) is a haploid cell that fuses with another haploid cell during fertilization in organisms that reproduce sexually. Gametes are an organism's reproductive cells, also referred to as sex cells. In species that produce ...
s. Some people with intersex traits use the term "intersex", and some prefer other language. In clinical settings, the term "disorders of sex development
Disorders of sex development (DSDs), also known as differences in sex development, diverse sex development and variations in sex characteristics (VSC), are congenital conditions affecting the reproductive system, in which development of chromo ...
" (DSD) has been used since 2006, a shift in language considered controversial since its introduction.
Intersex people face stigmatization and discrimination from birth, or following the discovery of intersex traits at stages of development such as puberty
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a bo ...
. Intersex people may face infanticide, abandonment, and stigmatization from their families. Globally, some intersex infants and children, such as those with ambiguous outer genitalia, are surgically or hormonally
A hormone (from the Greek participle , "setting in motion") is a class of signaling molecules in multicellular organisms that are sent to distant organs by complex biological processes to regulate physiology and behavior. Hormones are required fo ...
altered to create more socially acceptable sex characteristics. However, this is considered controversial, with no firm evidence of favorable outcomes.[Submission 88 to the Australian Senate inquiry on the involuntary or coerced sterilisation of people with disabilities in Australia](_blank)
, Australasian Paediatric Endocrine Group (APEG), 27 June 2013 Such treatments may involve sterilization. Adults, including elite female athletes, have also been subjects of such treatment. Increasingly, these issues are considered human rights abuse
Human rights are moral principles or normsJames Nickel, with assistance from Thomas Pogge, M.B.E. Smith, and Leif Wenar, 13 December 2013, Stanford Encyclopedia of PhilosophyHuman Rights Retrieved 14 August 2014 for certain standards of hum ...
s, with statements from international[Report of the UN Special Rapporteur on Torture](_blank)
, Office of the UN High Commissioner for Human Rights
The Office of the United Nations High Commissioner for Human Rights, commonly known as the Office of the High Commissioner for Human Rights (OHCHR) or the United Nations Human Rights Office, is a department of the Secretariat of the United Nati ...
, February 2013.[Eliminating forced, coercive and otherwise involuntary sterilization, An interagency statement](_blank)
, World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...
, May 2014. and national human rights and ethics institutions (see intersex human rights
Intersex people are born with sex characteristics, such as chromosomes, gonads, or genitals, that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies."
Intersex peo ...
). Intersex organizations have also issued statements about human rights violations, including the 2013 Malta declaration of the third International Intersex Forum
The International Intersex Forum is an annual event organised, then later supported, by the ILGA and ILGA-Europe that and organisations from multiple regions of the world, and it is believed to be the first and only such intersex event.
Predec ...
. In 2011, Christiane Völling
Christiane Völling (born 17 April 1959) is the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention described as a non-consensual sex reassignment. She was awarded €100,00 ...
became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention. In April 2015, Malta
Malta ( , , ), officially the Republic of Malta ( mt, Repubblika ta' Malta ), is an island country in the Mediterranean Sea. It consists of an archipelago, between Italy and Libya, and is often considered a part of Southern Europe. It lies ...
became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people.
Terminology
There is no clear consensus definition of intersex and no clear delineation of which specific conditions qualify an individual as intersex. The World Health Organization's International Classification of Diseases
The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
(ICD), the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and many medical journals classify intersex traits or conditions among disorders of sex development (DSD).
A common adjective for people with disorders of sex development
Disorders of sex development (DSDs), also known as differences in sex development, diverse sex development and variations in sex characteristics (VSC), are congenital conditions affecting the reproductive system, in which development of chromo ...
(DSD) is "intersex".
Etymology and definitions
In 1917, Richard Goldschmidt
Richard Benedict Goldschmidt (April 12, 1878 – April 24, 1958) was a German-born American geneticist. He is considered the first to attempt to integrate genetics, development, and evolution. He pioneered understanding of reaction norms, gen ...
created the term "intersexuality" to refer to a variety of physical sex ambiguities. However, according to ''The SAGE Encyclopedia of LGBTQ
' is an initialism that stands for lesbian, gay, bisexual, and transgender. In use since the 1990s, the initialism, as well as some of its common variants, functions as an umbrella term for sexuality and gender identity.
The LGBT term is ...
Studies'', it wasn't until Anne Fausto Sterling published her article "The Five Sexes: Why Male and Female Are Not Enough" in 1993 that the term reached popularity.
According to the UN Office of the High Commissioner for Human Rights:
Attitudes towards the term
Some intersex organizations reference "intersex people" and "intersex variations or traits" while others use more medicalized language such as "people with intersex conditions", or people "with intersex conditions or DSDs (differences of sex development)" and "children born with variations of sex anatomy". In May 2016, interACT
Advocates for Informed Choice, dba interACT or interACT Advocates for Intersex Youth, is a 501(c)(3) nonprofit organization using innovative strategies to advocate for the legal and human rights of children with intersex traits. The organizati ...
published a statement recognizing "increasing general understanding and acceptance of the term 'intersex'".
Australian sociological research on 272 "people born with atypical sex characteristics", published in 2016, found that 60% of respondents used the term "intersex" to self-describe their sex characteristics, including people identifying themselves as intersex, describing themselves as having an intersex variation or, in smaller numbers, having an intersex condition. Respondents also commonly used diagnostic labels and referred to their sex chromosomes, with word choices depending on audience.
Research on 202 respondents by the Lurie Children's Hospital
Ann & Robert H. Lurie Children's Hospital of Chicago, formerly Children's Memorial Hospital and commonly known as Lurie Children's, is a nationally ranked pediatric acute care children's hospital located in Chicago, Illinois. The hospital has 3 ...
, Chicago, and the AIS-DSD Support Group (now known as InterConnect Support Group) published in 2017 found that 80% of Support Group respondents "strongly liked, liked or felt neutral about intersex" as a term, while caregivers were less supportive. The hospital reported that the use of the term "disorders of sex development" may negatively affect care.
Another study by a group of children's hospitals in the United States found that 53% of 133 parent and adolescent participants recruited at five clinics did not like the term "intersex". Participants who were members of support groups were more likely to dislike the term. A "dsd-LIFE" study in 2020 found that around 43% of 179 participants thought the term "intersex" was bad, 20% felt neutral about the term, while the rest thought the term was good.
The term "hermaphrodite"
Historically, the term "hermaphrodite" was used in law to refer to people whose sex was in doubt. The 12th-century ''Decretum Gratiani
The ''Decretum Gratiani'', also known as the ''Concordia discordantium canonum'' or ''Concordantia discordantium canonum'' or simply as the ''Decretum'', is a collection of canon law compiled and written in the 12th century as a legal textbook b ...
'' states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails" ("Hermafroditus an ad testamentum adhiberi possit, qualitas sexus incalescentis ostendit."). Similarly, the 17th-century English jurist and judge Edward Coke (Lord Coke), wrote in his ''Institutes of the Lawes of England
The ''Institutes of the Lawes of England'' are a series of legal treatises written by Sir Edward Coke. They were first published, in stages, between 1628 and 1644. Widely recognized as a foundational document of the common law, they have been cit ...
'' on laws of succession stating, "Every heire is either a male, a female, or an hermaphrodite, that is both male and female. And an hermaphrodite (which is also called ''Androgynus'') shall be heire, either as male or female, according to that kind of sexe which doth prevaile."
During the Victorian era
In the history of the United Kingdom and the British Empire, the Victorian era was the period of Queen Victoria's reign, from 20 June 1837 until her death on 22 January 1901. The era followed the Georgian period and preceded the Edwardia ...
, medical authors attempted to ascertain whether or not humans could be hermaphrodites, adopting a precise biological definition for the term, and making distinctions between "male pseudohermaphrodite", "female pseudohermaphrodite" and especially "true hermaphrodite
True hermaphroditism, sometimes referred to as ovotesticular syndrome, is an intersex condition in which an individual is born with both ovarian and testicular tissue. Commonly, one or both gonads is an ovotestis containing both types of tissu ...
". These terms, which reflected histology
Histology,
also known as microscopic anatomy or microanatomy, is the branch of biology which studies the microscopic anatomy of biological tissues. Histology is the microscopic counterpart to gross anatomy, which looks at larger structures vi ...
(microscopic appearance) of the gonads, are no longer used. Until the mid-20th century, "hermaphrodite" was used synonymously with "intersex".[Cawadias, A. P. (1943) ''Hermaphoditus the Human Intersex'', London, Heinemann Medical Books Ltd.] Medical terminology shifted in the early 21st century, not only due to concerns about language, but also a shift to understandings based on genetics
Genetics is the study of genes, genetic variation, and heredity in organisms.Hartl D, Jones E (2005) It is an important branch in biology because heredity is vital to organisms' evolution. Gregor Mendel, a Moravian Augustinian friar wor ...
.
The Intersex Society of North America
The Intersex Society of North America (ISNA) was a non-profit advocacy group founded in 1993 by Cheryl Chase to end shame, secrecy, and unwanted genital surgeries.Matthews, Karen (Oct 22, 2000). Debate Grows Over Using Surgery on Infants with Amb ...
has stated that hermaphrodites should not be confused with intersex people and that using "hermaphrodite" to refer to intersex individuals is considered to be stigmatizing and misleading.
Prevalence
Estimates of the number of people who are intersex vary, depending on which conditions are counted as intersex.[ The now-defunct ]Intersex Society of North America
The Intersex Society of North America (ISNA) was a non-profit advocacy group founded in 1993 by Cheryl Chase to end shame, secrecy, and unwanted genital surgeries.Matthews, Karen (Oct 22, 2000). Debate Grows Over Using Surgery on Infants with Amb ...
stated that:
Anne Fausto-Sterling and her co-authors broadly said in 2000 that " ding the estimates of all known causes of nondimorphic sexual development suggests that approximately 1.7% of all live births do not conform to a Platonic ideal of absolute sex chromosome, gonadal, genital, and hormonal dimorphism"; these publications have been widely quoted by intersex activists. Of the 1.7 percent, 1.5 percentage points (88% of those considered "nondimorphic sexual development" in this figure) consist of individuals with late onset congenital adrenal hyperplasia
Late onset congenital adrenal hyperplasia (LOCAH), also known as nonclassic congenital adrenal hyperplasia (NCCAH or NCAH), is a milder form of congenital adrenal hyperplasia (CAH), a group of autosomal recessive disorders characterized by impaired ...
(LOCAH) which may be asymptomatic but can present after puberty and cause infertility.
In response to Fausto-Sterling, Leonard Sax
Leonard Sax is an American psychologist and a practicing family physician. He is best known as the author of three books for parents: ''Boys Adrift'', ''Girls on the Edge'', and ''Why Gender Matters''. According to his web site, he is currently ...
estimated that the prevalence of intersex was about 0.018% of the world's population,[Alt URL]
/ref> after discounting several conditions including LOCAH, Klinefelter syndrome (47,XXY), Turner syndrome (45,X), the chromosomal variants of 47,XYY and 47,XXX, and vaginal agenesis. Sax reasons that in these conditions chromosomal sex is consistent with phenotypic sex and phenotype is classifiable as either male or female.
In a 2003 letter to the editor, political scientist Carrie Hull analyzed the data used by Fausto-Sterling and said the estimated intersex rate should instead have been 0.37%, due to many errors. In a response letter published simultaneously, Fausto-Sterling welcomed the additional analysis and said "I am not invested in a particular final estimate, only that there BE an estimate". A 2018 review reported that the number of births with ambiguous genitals is in the range of 0.02% to 0.05%.
Intersex Human Rights Australia
Intersex Human Rights Australia (IHRA) is a voluntary organisation for intersex people that promotes the human rights and bodily autonomy of intersex people in Australia, and provides education and information services. Established in 2009 and ...
says it maintains 1.7% as its preferred upper limit "despite its flaws", stating both that the estimate "encapsulates the entire population of people who are stigmatized – or risk stigmatization – due to innate sex characteristics," and that Sax's definitions exclude individuals who experience such stigma and who have helped to establish the intersex movement.
The following summarizes prevalence
In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
s of traits that have been called intersex:
Prevalences of specific conditions can vary across regions. In the Dominican Republic
The Dominican Republic ( ; es, República Dominicana, ) is a country located on the island of Hispaniola in the Greater Antilles archipelago of the Caribbean region. It occupies the eastern five-eighths of the island, which it shares with ...
, 5-alpha-reductase deficiency is not uncommon in the town of Las Salinas, resulting in social acceptance of the intersex trait. Men with the trait are called "güevedoces" (Spanish for "eggs at twelve"). 12 out of 13 families had one or more male family members that carried the gene. The overall incidence for the town was 1 in every 90 males were carriers, with other males either non-carriers or non-affected carriers.
History
From early history, societies have been aware of intersex people. Some of the earliest evidence is found in mythology: the Greek historian Diodorus Siculus wrote of the mythological Hermaphroditus in the first century BC, who was "born with a physical body which is a combination of that of a man and that of a woman", and reputedly possessed supernatural properties. He also recounted the lives of Diophantus of Abae
Diophantus ( grc, Διόφαντος), born Herais ( grc, Ἡραΐς; 2nd century BC), was an intersex person who lived in the second century BC and fought as a soldier with Alexander Balas. His life is known from the works of Diodorus Siculus.
...
and Callon of Epidaurus Callon (born Callo) was an intersex person, who may have been a priestess and lived in the second century BC. The medical treatment he underwent is the first recorded example of gender affirmation surgery. His life is known from the works of Diodor ...
. Ardhanarishvara, an androgynous composite form of male deity Shiva
Shiva (; sa, शिव, lit=The Auspicious One, Śiva ), also known as Mahadeva (; ɐɦaːd̪eːʋɐ, or Hara, is one of the principal deities of Hinduism. He is the Supreme Being in Shaivism, one of the major traditions within Hindu ...
and female deity Parvati
Parvati ( sa, पार्वती, ), Uma ( sa, उमा, ) or Gauri ( sa, गौरी, ) is the Hindu goddess of power, energy, nourishment, harmony, love, beauty, devotion, and motherhood. She is a physical representation of Mahadevi i ...
, originated in Kushan culture as far back as the first century AD. A statue depicting Ardhanarishvara is included in India's Meenakshi Temple; this statue clearly shows both male and female bodily elements.
Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history o ...
( – BC Greek physician) and Galen
Aelius Galenus or Claudius Galenus ( el, Κλαύδιος Γαληνός; September 129 – c. AD 216), often Anglicized as Galen () or Galen of Pergamon, was a Greek physician, surgeon and philosopher in the Roman Empire. Considered to be one ...
(129 – AD Roman
Roman or Romans most often refers to:
*Rome, the capital city of Italy
*Ancient Rome, Roman civilization from 8th century BC to 5th century AD
*Roman people, the people of ancient Rome
*'' Epistle to the Romans'', shortened to ''Romans'', a lette ...
physician, surgeon and philosopher) both viewed sex as a spectrum between men and women, with "many shades in between, including hermaphrodites, a perfect balance of male and female". Pliny the Elder
Gaius Plinius Secundus (AD 23/2479), called Pliny the Elder (), was a Roman author, naturalist and natural philosopher, and naval and army commander of the early Roman Empire, and a friend of the emperor Vespasian. He wrote the encyclopedic ' ...
(AD 23/24–79) the Roman naturalist described "those who are born of both sexes, whom we call hermaphrodites, at one time ''androgyn
Androgyny is the possession of both masculine and feminine characteristics. Androgyny may be expressed with regard to biological sex, gender identity, or gender expression.
When ''androgyny'' refers to mixed biological sex characteristics in h ...
i''" (from the Greek
Greek may refer to:
Greece
Anything of, from, or related to Greece, a country in Southern Europe:
*Greeks, an ethnic group.
*Greek language, a branch of the Indo-European language family.
**Proto-Greek language, the assumed last common ancestor ...
, "man," and , "woman"). Augustine
Augustine of Hippo ( , ; la, Aurelius Augustinus Hipponensis; 13 November 354 – 28 August 430), also known as Saint Augustine, was a theologian and philosopher of Berber origin and the bishop of Hippo Regius in Numidia, Roman North A ...
(354 – 28 August 430 AD) the influential Catholic theologian wrote in ''The Literal Meaning of Genesis'' that humans were created in two sexes, despite "as happens in some births, in the case of what we call androgynes".
In medieval and early modern European societies, Roman law
Roman law is the legal system of ancient Rome, including the legal developments spanning over a thousand years of jurisprudence, from the Twelve Tables (c. 449 BC), to the '' Corpus Juris Civilis'' (AD 529) ordered by Eastern Roman emperor Ju ...
, post-classical canon law
Canon law (from grc, κανών, , a 'straight measuring rod, ruler') is a set of ordinances and regulations made by ecclesiastical authority (church leadership) for the government of a Christian organization or church and its members. It is th ...
, and later common law
In law, common law (also known as judicial precedent, judge-made law, or case law) is the body of law created by judges and similar quasi-judicial tribunals by virtue of being stated in written opinions."The common law is not a brooding omnipres ...
, referred to a person's sex as male, female or hermaphrodite, with legal rights as male or female depending on the characteristics that appeared most dominant. The 12th century states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails". The foundation of common law, the 17th Century ''Institutes of the Lawes of England
The ''Institutes of the Lawes of England'' are a series of legal treatises written by Sir Edward Coke. They were first published, in stages, between 1628 and 1644. Widely recognized as a foundational document of the common law, they have been cit ...
'' described how a hermaphrodite could inherit "either as male or female, according to that kind of sexe which doth prevaile." Legal cases have been described in canon law and elsewhere over the centuries.
Some non-European societies have sex or gender
Though the terms '' sex'' and ''gender'' have been used interchangeably since at least the fourteenth century, in contemporary academic literature they usually have distinct meanings. ''Sex'' generally refers to an organism's biological sex, while ...
systems that recognize more than the two categories of male/man and female/woman. Some of these cultures, for instance the South-Asian Hijra
Hijra, Hijrah, Hegira, Hejira, Hijrat or Hijri may refer to:
Islam
* Hijrah (often written as ''Hejira'' in older texts), the migration of Muhammad from Mecca to Medina in 622 CE
* Migration to Abyssinia or First Hegira, of Muhammad's followers ...
communities, may include intersex people in a third gender
Third gender is a concept in which individuals are categorized, either by themselves or by society, as neither man nor woman. It is also a social category present in societies that recognize three or more genders. The term ''third'' is usuall ...
category. Although–according to Morgan Holmes
Morgan Holmes is a Canadian sociologist, author, and a professor at Wilfrid Laurier University, Ontario. She is also an intersex activist and writer, and former member of Intersex Society of North America. Holmes participated in the first public ...
–early Western anthropologists categorized such cultures "primitive," Holmes has argued that analyses of these cultures have been simplistic or romanticized and fail to take account of the ways that subjects of all categories are treated.
During the Victorian era
In the history of the United Kingdom and the British Empire, the Victorian era was the period of Queen Victoria's reign, from 20 June 1837 until her death on 22 January 1901. The era followed the Georgian period and preceded the Edwardia ...
, medical authors introduced the terms "true hermaphrodite
True hermaphroditism, sometimes referred to as ovotesticular syndrome, is an intersex condition in which an individual is born with both ovarian and testicular tissue. Commonly, one or both gonads is an ovotestis containing both types of tissu ...
" for an individual who has both ovarian and testicular tissue, "male pseudo-hermaphrodite" for a person with testicular tissue, but either female or ambiguous sexual anatomy, and "female pseudo-hermaphrodite" for a person with ovarian tissue, but either male or ambiguous sexual anatomy. Some later shifts in terminology have reflected advances in genetics, while other shifts are suggested to be due to pejorative associations.
The term "intersexuality" was coined by Richard Goldschmidt
Richard Benedict Goldschmidt (April 12, 1878 – April 24, 1958) was a German-born American geneticist. He is considered the first to attempt to integrate genetics, development, and evolution. He pioneered understanding of reaction norms, gen ...
in 1917. The first suggestion to replace the term "hermaphrodite" with "intersex" was made by Cawadias in the 1940s.
Since the rise of modern medical science, some intersex people with ambiguous external genitalia have had their genitalia surgically modified to resemble either female or male genitals. Surgeons pinpointed intersex babies as a "social emergency" when born. An 'optimal gender policy', initially developed by John Money
John William Money (8 July 1921 – 7 July 2006) was a New Zealand psychologist, sexologist and author known for his research into sexual identity and Sex determination and differentiation (human), biology of gender. He was one of the first ...
, stated that early intervention helped avoid gender identity confusion, but this lacks evidence. Early interventions have adverse consequences for psychological and physical health. Since advances in surgery have made it possible for intersex conditions to be concealed, many people are not aware of how frequently intersex conditions arise in human beings or that they occur at all.
Dialogue between what were once antagonistic groups of activists and clinicians has led to only slight changes in medical policies and how intersex patients and their families are treated in some locations. In 2011, Christiane Völling
Christiane Völling (born 17 April 1959) is the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention described as a non-consensual sex reassignment. She was awarded €100,00 ...
became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention. In April 2015, Malta
Malta ( , , ), officially the Republic of Malta ( mt, Repubblika ta' Malta ), is an island country in the Mediterranean Sea. It consists of an archipelago, between Italy and Libya, and is often considered a part of Southern Europe. It lies ...
became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people. Many civil society organizations and human rights institutions now call for an end to unnecessary "normalizing" interventions, including in the Malta declaration.
Human rights and legal issues
Human rights institutions are placing increasing scrutiny on harmful practices and issues of discrimination against intersex people. These issues have been addressed by a rapidly increasing number of international institutions including, in 2015, the Council of Europe, the United Nations and the World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...
(WHO). These developments have been accompanied by International Intersex Forum
The International Intersex Forum is an annual event organised, then later supported, by the ILGA and ILGA-Europe that and organisations from multiple regions of the world, and it is believed to be the first and only such intersex event.
Predec ...
s and increased cooperation amongst civil society organizations. However, the implementation, codification, and enforcement of intersex human rights in national legal systems remains slow.
Physical integrity and bodily autonomy
Stigmatization and discrimination from birth may include infanticide, abandonment, and the stigmatization of families. The birth of an intersex child was often viewed as a curse or a sign of a witch mother, especially in parts of Africa. Abandonments and infanticides have been reported in Uganda
}), is a landlocked country in East Africa. The country is bordered to the east by Kenya, to the north by South Sudan, to the west by the Democratic Republic of the Congo, to the south-west by Rwanda, and to the south by Tanzania. The sou ...
, Kenya
)
, national_anthem = " Ee Mungu Nguvu Yetu"()
, image_map =
, map_caption =
, image_map2 =
, capital = Nairobi
, coordinates =
, largest_city = Nairobi
...
, South Asia
South Asia is the southern subregion of Asia, which is defined in both geographical
Geography (from Greek: , ''geographia''. Combination of Greek words ‘Geo’ (The Earth) and ‘Graphien’ (to describe), literally "earth descr ...
, and China.
Infants, children and adolescents also experience "normalising" interventions on intersex persons that are medically unnecessary and the pathologisation of variations in sex characteristics. In countries where the human rights of intersex people have been studied, medical interventions to modify the sex characteristics of intersex people have still taken place without the consent of the intersex person. Interventions have been described by human rights defenders as a violation of many rights, including (but not limited to) bodily integrity, non-discrimination, privacy, and experimentation. These interventions have frequently been performed with the consent of the intersex person's parents, when the person is legally too young to consent. Such interventions have been criticized by the WHO, other UN bodies such as the Office of the High Commissioner for Human Rights, and an increasing number of regional and national institutions due to their adverse consequences, including trauma, impact on sexual function and sensation, and violation of rights to physical and mental integrity. The UN organizations decided that infant intervention should not be allowed, in favor of waiting for the child to mature enough to be a part of the decision-making – this allows for a decision to be made with total consent. In April 2015, Malta
Malta ( , , ), officially the Republic of Malta ( mt, Repubblika ta' Malta ), is an island country in the Mediterranean Sea. It consists of an archipelago, between Italy and Libya, and is often considered a part of Southern Europe. It lies ...
became the first country to outlaw surgical intervention without consent. In the same year, the Council of Europe became the first institution to state that intersex people have the right not to undergo sex affirmation interventions.
Anti-discrimination and equal treatment
People born with intersex bodies are seen as different. Intersex infants, children, adolescents and adults "are often stigmatized and subjected to multiple human rights violations", including discrimination in education, healthcare, employment, sport, and public services. Several countries have so far explicitly protected intersex people from discrimination, with landmarks including South Africa
South Africa, officially the Republic of South Africa (RSA), is the Southern Africa, southernmost country in Africa. It is bounded to the south by of coastline that stretch along the Atlantic Ocean, South Atlantic and Indian Oceans; to the ...
,[Government Gazette](_blank)
, Republic of South Africa, Vol. 487, Cape Town, 11 January 2006. Australia,[Sex Discrimination Amendment (Sexual Orientation, Gender Identity and Intersex Status) Act 2013, No. 98, 2013](_blank)
, ComLaw, C2013A00098, 2013.[On the historic passing of the Sex Discrimination Amendment (Sexual Orientation, Gender Identity and Intersex Status) Act 2013](_blank)
, Organisation Intersex International Australia
Intersex Human Rights Australia (IHRA) is a voluntary organisation for intersex people that promotes the human rights and bodily autonomy of intersex people in Australia, and provides education and information services. Established in 2009 and ...
, 25 June 2013. and, most comprehensively, Malta.
Remedies and claims for compensation
Claims for compensation and remedies for human rights abuses include the 2011 case of Christiane Völling
Christiane Völling (born 17 April 1959) is the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention described as a non-consensual sex reassignment. She was awarded €100,00 ...
in Germany
Germany,, officially the Federal Republic of Germany, is a country in Central Europe. It is the second most populous country in Europe after Russia, and the most populous member state of the European Union. Germany is situated betwe ...
. A second case was adjudicated in Chile
Chile, officially the Republic of Chile, is a country in the western part of South America. It is the southernmost country in the world, and the closest to Antarctica, occupying a long and narrow strip of land between the Andes to the east a ...
in 2012, involving a child and his parents. A further successful case in Germany, taken by Michaela Raab, was reported in 2015. In the United States, the Minor Child ( ''M.C. v Aaronson'') lawsuit was "a medical malpractice case related to the informed consent for a surgery performed on the Crawford's adopted child (known as M.C.) at edical University of South Carolinain April 2006". The case was one of the first lawsuit of its kind to challenge "legal, ethical, and medical issues regarding genital-normalizing surgery" in minors, and was eventually settled out of court by the Medical University of South Carolina for $440,000 in 2017.
Information and support
Access to information
Access may refer to:
Companies and organizations
* ACCESS (Australia), an Australian youth network
* Access (credit card), a former credit card in the United Kingdom
* Access Co., a Japanese software company
* Access Healthcare, an Indian BPO s ...
, medical records, peer and other counselling and support. With the rise of modern medical science in Western societies, a secrecy-based model was also adopted, in the belief that this was necessary to ensure normal physical and psychosocial development.
Legal recognition
The Asia Pacific Forum
The Asia Pacific Forum (APF) is one of four regional networks of national human rights institutions (NHRIs) within the International Co-ordinating Committee of NHRIs. The APF formerly accredited NHRIs for compliance with the United Nations' Pari ...
of National Human Rights Institutions
A national human rights institution (NHRI) is an independent state-based institution with the responsibility to broadly protect and promote human rights in a given country. The growth of such bodies has been encouraged by the Office of the United ...
states that legal recognition
Legal recognition of a status or fact in a jurisdiction is formal acknowledgement of it as being true, valid, legal, or worthy of consideration, and may involve approval or the granting of rights.
For example, a nation or territory may require a ...
is firstly "about intersex people who have been issued a male or a female birth certificate being able to enjoy the same legal rights as other men and women." In some regions, obtaining any form of birth certification may be an issue. A Kenyan court case in 2014 established the right of an intersex boy, "Baby A", to a birth certificate.
Like all individuals, some intersex individuals may be raised as a certain sex (male or female) but then identify with another later in life, while most do not. Recognition of third sex or gender classifications occurs in several countries, However, it is controversial when it becomes assumed or coercive, as is the case with some German infants. Sociological research in Australia, a country with a third 'X' sex classification, shows that 19% of people born with atypical sex characteristics selected an "X" or "other" option, while 75% of survey respondents self-described as male or female (52% as women, 23% as men), and 6% as unsure.
LGBT and LGBTI
Intersex conditions can be contrasted with transgender
A transgender (often abbreviated as trans) person is someone whose gender identity or gender expression does not correspond with their sex assigned at birth. Many transgender people experience dysphoria, which they seek to alleviate through ...
gender identities and the attached gender dysphoria a transgender person may feel, wherein their gender identity does not match their assigned sex. However, some people are both intersex and transgender; though intersex people by definition have variable sex characteristics that do not align with either typically male or female, this may be considered separate to an individual's assigned gender, the way they are raised and perceived, and their internal gender identity. A 2012 clinical review paper found that between 8.5% and 20% of people with intersex variations experienced gender dysphoria. In an analysis of the use of preimplantation genetic diagnosis
Preimplantation genetic diagnosis (PGD or PIGD) is the genetic profiling of embryos prior to implantation (as a form of embryo profiling), and sometimes even of oocytes prior to fertilization. PGD is considered in a similar fashion to prenatal ...
to eliminate intersex traits, Behrmann and Ravitsky state: "Parental choice against intersex may ... conceal biases against same-sex attractedness and gender nonconformity."
The relationship of intersex people and communities to LGBTQ communities is complex, but intersex people are often added to the LGBT
' is an initialism that stands for lesbian, gay, bisexual, and transgender. In use since the 1990s, the initialism, as well as some of its common variants, functions as an umbrella term for sexuality and gender identity.
The LGBT term ...
acronym, resulting in the acronym LGBTI. Emi Koyama describes how inclusion of intersex in LGBTI can fail to address intersex-specific human rights issues, including creating false impressions "that intersex people's rights are protected" by laws protecting LGBT people, and failing to acknowledge that many intersex people are not LGBT. Organisation Intersex International Australia
Intersex Human Rights Australia (IHRA) is a voluntary organisation for intersex people that promotes the human rights and bodily autonomy of intersex people in Australia, and provides education and information services. Established in 2009 and ...
states that some intersex individuals are homosexual, and some are heterosexual, but "LGBTI activism has fought for the rights of people who fall outside of expected binary sex and gender norms." Julius Kaggwa
Julius Kaggwa is a prominent Ugandan intersex and transgender activist and executive director of intersex support organization ''Support Initiative for People with atypical sex Development'' (SIPD). In 2010, Kaggwa was a joint winner of the Human R ...
of SIPD Uganda has written that, while the gay community "offers us a place of relative safety, it is also oblivious to our specific needs". Mauro Cabral
Mauro Cabral Grinspan, also known as Mauro Cabral, is an Argentinian intersex and trans activist, who serves as the executive director of GATE. A signatory of the Yogyakarta Principles, his work focuses on the reform of medical protocols and law ...
has written that transgender people and organizations "need to stop approaching intersex issues as if they were trans issues", including use of intersex conditions and people as a means of explaining being transgender; "we can collaborate a lot with the intersex movement by making it clear how wrong that approach is".
In society
Fiction, literature and media
An intersex character is the narrator in Jeffrey Eugenides
Jeffrey Kent Eugenides (born March 8, 1960) is an American novelist and short story writer. He has written numerous short stories and essays, as well as three novels: ''The Virgin Suicides'' (1993), ''Middlesex'' (2002), and'' The Marriage Plot'' ...
' Pulitzer Prize-winning novel ''Middlesex
Middlesex (; abbreviation: Middx) is a historic county in southeast England. Its area is almost entirely within the wider urbanised area of London and mostly within the ceremonial county of Greater London, with small sections in neighbour ...
''.
The memoir, ''Born Both: An Intersex Life'' (Hachette Books
Hachette Books, formerly Hyperion Books, is a general-interest book imprint of the Perseus Books Group, which is a division of Hachette Book Group and ultimately a part of Lagardère Group. Established in 1990, Hachette publishes general-inte ...
, 2017), by intersex author and activist Hida Viloria
Hida Viloria (born May 29, 1968) is a Latine American writer, author, producer, and human rights activist.
Viloria is intersex, nonbinary, and gender nonconforming, using they/them pronouns. They are known for their writing, their intersex and ...
, received strong praise from ''The New York Times Book Review
''The New York Times Book Review'' (''NYTBR'') is a weekly paper-magazine supplement to the Sunday edition of ''The New York Times'' in which current non-fiction and fiction books are reviewed. It is one of the most influential and widely rea ...
'', ''The Washington Post
''The Washington Post'' (also known as the ''Post'' and, informally, ''WaPo'') is an American daily newspaper published in Washington, D.C. It is the most widely circulated newspaper within the Washington metropolitan area and has a large nati ...
'', ''Rolling Stone
''Rolling Stone'' is an American monthly magazine that focuses on music, politics, and popular culture. It was founded in San Francisco, California, in 1967 by Jann Wenner, and the music critic Ralph J. Gleason. It was first known for its ...
'', ''People Magazine
''People'' is an American weekly magazine that specializes in celebrity news and human-interest stories. It is published by Dotdash Meredith, a subsidiary of IAC. With a readership of 46.6 million adults in 2009, ''People'' had the lar ...
'', and '' Psychology Today'', was one of ''School Library Journal
''School Library Journal'' (''SLJ'') is an American monthly magazine containing reviews and other articles for school librarians, media specialists, and public librarians who work with young people. Articles cover a wide variety of topics, with ...
s 2017 Top Ten Adult Books for Teens, and was a 2018 Lambda Literary Award
Lambda Literary Awards, also known as the "Lammys", are awarded yearly by Lambda Literary to recognize the crucial role LGBTQ writers play in shaping the world. The Lammys celebrate the very best in LGBTQ literature.The awards were instituted i ...
nominee.
Television works about intersex
Intersex, in humans and other animals, describes variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary not ...
and films about intersex
Intersex, in humans and other animals, describes variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary not ...
are scarce. The Spanish-language film '' XXY'' won the Critics' Week grand prize at the 2007 Cannes Film Festival
The Cannes Festival (; french: link=no, Festival de Cannes), until 2003 called the International Film Festival (') and known in English as the Cannes Film Festival, is an annual film festival held in Cannes, France, which previews new films o ...
and the ACID/CCAS Support Award. '' Faking It'' is notable for providing both the first intersex main character in a television show, and television's first intersex character played by an intersex actor.
Civil society institutions
Intersex peer support and advocacy organizations have existed since at least 1985, with the establishment of the Androgen Insensitivity Syndrome Support Group Australia
Intersex Peer Support Australia (IPSA), also known as the Androgen Insensitivity Syndrome Support Group Australia, is possibly the oldest known intersex organization, established in 1985. It provides peer and family support, information and advo ...
in 1985. The Androgen Insensitivity Syndrome Support Group (UK) was established in 1988. The Intersex Society of North America
The Intersex Society of North America (ISNA) was a non-profit advocacy group founded in 1993 by Cheryl Chase to end shame, secrecy, and unwanted genital surgeries.Matthews, Karen (Oct 22, 2000). Debate Grows Over Using Surgery on Infants with Amb ...
(ISNA) may have been one of the first intersex civil society organizations to have been open to people regardless of diagnosis; it was active from 1993 to 2008.
Events
Intersex Awareness Day
Intersex Awareness Day is an internationally observed awareness day each October 26, designed to highlight human rights issues faced by intersex people.
History
The event marks the first public demonstration by intersex people in North America ...
is an internationally observed civil awareness day designed to highlight the challenges faced by intersex people, occurring annually on 26 October. It marks the first public demonstration by intersex people, which took place in Boston on 26 October 1996, outside a venue where the American Academy of Pediatrics was holding its annual conference.
Intersex Day of Remembrance
Intersex Day of Remembrance, also known as Intersex Solidarity Day, is an internationally observed civil awareness day designed to highlight issues faced by intersex people. It marks the birthday of Herculine Barbin, a French intersex person who ...
, also known as Intersex Solidarity Day, is an internationally observed civil awareness day designed to highlight issues faced by intersex people, occurring annually on 8 November. It marks the birthday of , a French intersex person whose memoirs were later published by Michel Foucault in '' Herculine Barbin: Being the Recently Discovered Memoirs of a Nineteenth-century French Hermaphrodite.''
Flag
The intersex flag
The intersex flag is a pride flag representing intersex individuals and the intersex community. It was created by Morgan Carpenter of Intersex Human Rights Australia in 2013.
History and design
The flag was created in July 2013 by Morgan Carpen ...
was created in July 2013 by Morgan Carpenter
Morgan Carpenter is a bioethicist, intersex activist and researcher. In 2013 he created the intersex flag, and became president of Intersex Human Rights Australia (formerly OII Australia). He is now a co-executive director. In 2015, he cofound ...
of Intersex Human Rights Australia
Intersex Human Rights Australia (IHRA) is a voluntary organisation for intersex people that promotes the human rights and bodily autonomy of intersex people in Australia, and provides education and information services. Established in 2009 and ...
to create a flag "that is not derivative, but is yet firmly grounded in meaning". The circle is described as "unbroken and unornamented, symbolising wholeness and completeness, and our potentialities. We are still fighting for bodily autonomy and genital integrity, and this symbolises the right to be who and how we want to be."[An intersex flag](_blank)
Intersex Human Rights Australia
Intersex Human Rights Australia (IHRA) is a voluntary organisation for intersex people that promotes the human rights and bodily autonomy of intersex people in Australia, and provides education and information services. Established in 2009 and ...
, 5 July 2013
Religion
In Judaism
Judaism ( he, ''Yahăḏūṯ'') is an Abrahamic, monotheistic, and ethnic religion comprising the collective religious, cultural, and legal tradition and civilization of the Jewish people. It has its roots as an organized religion in t ...
, the Talmud
The Talmud (; he, , Talmūḏ) is the central text of Rabbinic Judaism and the primary source of Jewish religious law ('' halakha'') and Jewish theology. Until the advent of modernity, in nearly all Jewish communities, the Talmud was the ce ...
contains extensive discussion concerning the status of two types of intersex people in Jewish law; namely, the androgynous, who exhibit both male and female external sexual organs, and the , who exhibit neither. In the 1970s and 1980s, the treatment of intersex babies started to be discussed in Orthodox Jewish medical halacha
''Halakha'' (; he, הֲלָכָה, ), also transliterated as ''halacha'', ''halakhah'', and ''halocho'' ( ), is the collective body of Jewish religious laws which is derived from the written and Oral Torah. Halakha is based on biblical comman ...
by prominent rabbinic leaders, such as Eliezer Waldenberg
Eliezer Yehuda Waldenberg ( he, הרב אליעזר יהודה וולדנברג; December 10, 1915 – November 21, 2006) was a rabbi, posek, and dayan in Jerusalem. He is known as a leading authority on medicine and Jewish law and referred to as ...
and Moshe Feinstein
Moshe Feinstein ( he, משה פײַנשטיין; Lithuanian pronunciation: ''Moshe Faynshteyn''; en, Moses Feinstein; March 3, 1895 – March 23, 1986) was an American Orthodox rabbi, scholar, and ''posek'' (authority on ''halakha''—J ...
.
Sport
Erik Schinegger
Erik Schinegger (born 19 June 1948) is an Austrian intersex skier. He was the women's downhill ski world champion in 1966, at which time he was recognized as female and known as Erika Schinegger.
Biography
Schinegger was born in Agsdorf, Carint ...
, Foekje Dillema
Foekje Dillema (18 September 1926 – 5 December 2007) was a Dutch track and field athlete.
Biography
Dillema was named "athlete of the match" in 1949 after winning the 100 metres and 200 metres race during a tournament in London. She was an im ...
, Maria José Martínez-Patiño
Maria José Martínez-Patiño (born 10 July 1961) is a Spanish former hurdler, whose dismissal from the Spanish Olympic team in 1986 for failing the gender test is a notable moment in the history of sex verification in sports.
Martínez-Patiño wa ...
and Santhi Soundarajan
Santhi Soundarajan (also spelled ''Shanthi Soundararajan'', ta, சாந்தி சௌந்திரராஜன், born 17 April 1981) is a track and field athlete from Tamil Nadu, India. She is the winner of 12 int ...
were subject to adverse sex verification testing resulting in ineligibility to compete in organised competitive competition. Stanisława Walasiewicz was posthumously ruled ineligible to have competed.
The South African middle-distance runner Caster Semenya
Mokgadi Caster Semenya OIB (born 7 January 1991) is a South African middle-distance runner and winner of two Olympic gold medals and three World Championships in the women's 800 metres. She first won gold at the World Championships in 2009 ...
won gold at the World Championships in the women's 800 metres and won silver in the 2012 Summer Olympics. When Semenya won gold in the World Championships, the International Association of Athletics Federations
World Athletics, formerly known as the International Amateur Athletic Federation (from 1912 to 2001) and International Association of Athletics Federations (from 2001 to 2019, both abbreviated as the IAAF) is the international governing body fo ...
(IAAF) requested sex verification tests. The results were not released. Semenya was ruled eligible to compete.
Katrina Karkazis
Katrina Alicia Karkazis (born 1970) is an anthropologist and bioethicist. She is a professor of Sexuality, Women's and Gender Studies at Amherst College. She was previously the Carol Zicklin Endowed Chair in the Honors Academy at Brooklyn College ...
, Rebecca Jordan-Young
Rebecca M. Jordan-Young (born 1963), is an American feminist scientist and gender studies scholar. Her research focuses on social medical science, sex, gender, sexuality, and epidemiology. She is an Associate Professor of Women’s, Gender, and ...
, Georgiann Davis
Georgiann Davis is an associate professor of sociology at the University of New Mexico and author of the book ''Contesting Intersex: The Dubious Diagnosis''. Davis formerly held similar positions at University of Nevada, Las Vegas and Southern I ...
and Silvia Camporesi have claimed that IAAF policies on "hyperandrogenism" in female athletes are "significantly flawed", arguing that the policy does not protect against breaches of privacy, requires athletes to undergo unnecessary treatment in order to compete, and intensifies "gender policing", and recommended that athletes be able to compete in accordance with their legally-recognised gender.
In April 2014, the '' BMJ'' reported that four elite women athletes with XY chromosomes and 5-ARD were subjected to sterilization and "partial clitoridectomies" in order to compete in sport. The authors noted that partial clitoridectomy was "not medically indicated" and "does not relate to real or perceived athletic 'advantage'." Intersex advocates regarded this intervention as "a clearly coercive process". In 2016, the United Nations Special Rapporteur on health, Dainius Pūras, criticized "current and historic" sex verification policies, describing how "a number of athletes have undergone gonadectomy (removal of reproductive organs) and partial clitoridectomy (a form of female genital mutilation) in the absence of symptoms or health issues warranting those procedures."
Biology
The notion of intersex individuals can be understood in the context of sexual system biology that varies across different types of organisms. Most animal species (~95%, including humans) are gonochoric
In biology, gonochorism is a sexual system where there are only two sexes and each individual organism is either male or female. The term gonochorism is usually applied in animal species, the vast majority of which are gonochoric.
Gonochorism c ...
, in which individuals are of either a female or male sex. Hermaphroditic species (some animals and most flowering plants) are represented by individuals that can express both sexes simultaneously or sequentially during their lifetimes. Intersex individuals in a number of gonochoric species, who express both female and male phenotypic characters to some degree, are known to exist at very low prevalences.
Although "hermaphrodite" and "intersex" have been used synonymously in humans, a hermaphrodite is specifically an individual capable of producing female and male gametes. While there are reports of individuals that seemed to have the potential to produce both types of gamete, in more recent years the term hermaphrodite as applied to humans has fallen out of favor, since female and male reproductive functions have not been observed together in the same individual.
Medical
Research in the late 20th century led to a growing medical consensus that diverse intersex bodies are normal, but relatively rare, forms of human biology. Clinician and researcher Milton Diamond
Milton Diamond (born March 6, 1934) is an American Professor Emeritus of anatomy and reproductive biology at the University of Hawaiʻi at Mānoa. After a career in the study of human sexuality, Diamond retired from the university in December 20 ...
stresses the importance of care in the selection of language related to intersex people:
Medical classifications
Sexual differentiation
The common pathway of sexual differentiation
Sexual differentiation is the process of development of the sex differences between males and females from an undifferentiated zygote. Sex determination is often distinct from sex differentiation; sex determination is the designation for the dev ...
, where a productive human female has an XX chromosome pair, and a productive male has an XY pair, is relevant to the development of intersex conditions.
During fertilization, the sperm adds either an X (female) or a Y (male) chromosome to the X in the ovum. This determines the genetic sex of the embryo. During the first weeks of development, genetic male and female fetuses are "anatomically indistinguishable", with primitive gonads beginning to develop during approximately the sixth week of gestation. The gonads, in a bipotential state, may develop into either testes (the male gonads) or ovaries (the female gonads), depending on the consequent events. Up until and including the seventh week, genetically female and genetically male fetuses appear identical.
At around eight weeks of gestation, the gonads of an XY embryo differentiate into functional testes, secreting testosterone. Ovarian differentiation, for XX embryos, does not occur until approximately week 12 of gestation. In typical female differentiation, the Müllerian duct system develops into the uterus
The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...
, Fallopian tubes
The fallopian tubes, also known as uterine tubes, oviducts or salpinges (singular salpinx), are paired tubes in the human female that stretch from the uterus to the ovaries. The fallopian tubes are part of the female reproductive system. In ot ...
, and inner third of the vagina.
In males, the Müllerian duct-inhibiting hormone MIH causes this duct system to regress. Next, androgens cause the development of the Wolffian duct system, which develops into the vas deferens
The vas deferens or ductus deferens is part of the male reproductive system of many vertebrates. The ducts transport sperm from the epididymis to the ejaculatory ducts in anticipation of ejaculation. The vas deferens is a partially coiled tube ...
, seminal vesicles, and ejaculatory ducts.
By birth, the typical fetus has been completely sexed male or female, meaning that the genetic sex (XY-male or XX-female) corresponds with the phenotypical sex; that is to say, genetic sex corresponds with internal and external gonads, and external appearance of the genitals.
Signs
There are a variety of symptoms that can occur. Ambiguous genitalia is the most common sign. There can be micropenis
Micropenis is an unusually small penis. A common criterion is a dorsal (measured on top) penile length of at least 2.5 standard deviations smaller than the mean human penis size (stretched penile length less than 9.3 cm (3.67 in) in adults). ...
, clitoromegaly
Clitoromegaly (or macroclitoris) is an abnormal enlargement of the clitoris that is mostly congenital or acquired, though deliberately induced clitoris enlargement as a form of genital body modification is achieved through various uses of anabo ...
, partial labial fusion
Labial fusion is a medical condition of the female genital anatomy where the labia minora become fused together. It is generally a pediatric condition.
Presentation
Labial fusion is rarely present at birth, but rather acquired later in infancy, s ...
, electrolyte abnormalities, delayed or absent puberty, unexpected changes at puberty, hypospadias, labial or inguinal (groin) masses (which may turn out to be testes) in girls and undescended testes (which may turn out to be ovaries) in boys.
Ambiguous genitalia
Ambiguous genitalia may appear as a large clitoris or as a small penis.
Because there is variation in all of the processes of the development of the sex organs, a child can be born with a sexual anatomy
A sex organ (or reproductive organ) is any part of an animal or plant that is involved in sexual reproduction. The reproductive organs together constitute the reproductive system. In animals, the testis in the male, and the ovary in the female, a ...
that is typically female or feminine in appearance with a larger-than-average clitoris (clitoral hypertrophy
Clitoromegaly (or macroclitoris) is an abnormal enlargement of the clitoris that is mostly congenital or acquired, though deliberately induced clitoris enlargement as a form of genital body modification is achieved through various uses of anaboli ...
) or typically male or masculine in appearance with a smaller-than-average penis
A penis (plural ''penises'' or ''penes'' () is the primary sexual organ that male animals use to inseminate females (or hermaphrodites) during copulation. Such organs occur in many animals, both vertebrate and invertebrate, but males d ...
that is open along the underside. The appearance may be quite ambiguous, describable as female genitals with a very large clitoris and partially fused labia, or as male genitals with a very small penis, completely open along the midline (" hypospadic"), and empty scrotum. Fertility is variable.
Measurement systems for ambiguous genitalia
The orchidometer
An orchidometer (or orchiometer) is a medical instrument used to measure the volume of the testicles.
The orchidometer was introduced in 1966 by Swiss pediatric endocrinologist Andrea Prader of the University of Zurich. It consists of a string of ...
is a medical instrument to measure the volume of the testicles. It was developed by Swiss pediatric endocrinologist Andrea Prader
Andrea is a given name which is common worldwide for both males and females, cognate to Andreas, Andrej and Andrew.
Origin of the name
The name derives from the Greek word ἀνήρ (''anēr''), genitive ἀνδρός (''andrós''), that re ...
. The Prader scale
The Prader scale or Prader staging, named after Andrea Prader, is a coarse rating system for the measurement of the degree of virilization of the Sex organ, genitalia of the human body and is similar to the Quigley scale. It primarily relates to v ...
and Quigley scale
The Quigley scale is a descriptive, visual system of phenotypic grading that defines seven classes between "fully masculinized" and "fully feminized" genitalia. It was proposed by pediatric endocrinologist Charmian A. Quigley et al. in 1995. It is ...
are visual rating systems that measure genital appearance. These measurement systems were satirized in the Phall-O-Meter
The Phall-O-meter is a satirical measure that critiques medical standards for normal male and female phalluses. The tool was developed by Kiira Triea (Denise Tree) based on a concept by Suzanne Kessler and is used to demonstrate concerns with the ...
, created by the (now defunct) Intersex Society of North America
The Intersex Society of North America (ISNA) was a non-profit advocacy group founded in 1993 by Cheryl Chase to end shame, secrecy, and unwanted genital surgeries.Matthews, Karen (Oct 22, 2000). Debate Grows Over Using Surgery on Infants with Amb ...
.
Other signs
In order to help in classification, methods other than a genitalia inspection can be performed. For instance, a karyotype display of a tissue sample may determine which of the causes of intersex is prevalent in the case. Additionally, electrolyte tests, endoscopic exam, ultrasound and hormone stimulation tests can be done.
Causes
Intersex can be divided into four categories which are: 46, XX intersex; 46, XY intersex; true gonadal intersex; and complex or undetermined intersex.
=46, XX intersex
=
This condition used to be called "female pseudohermaphroditism
Pseudohermaphroditism is a condition in which an individual has a matching chromosomal and gonadal tissue (ovary or testis) sex, but mismatching external genitalia.
Female pseudohermaphroditism refers to an individual with ovaries and external gen ...
". Persons with this condition have female internal genitalia and karyotype (XX) and various degree of external genitalia virilization
Virilization or masculinization is the biological development of adult male characteristics in young males or females. Most of the changes of virilization are produced by androgens.
Virilization is most commonly used in three medical and biology ...
. External genitalia is masculinized congenitally when female fetus is exposed to excess androgenic environment. Hence, the chromosome of the person is of a woman, the ovaries of a woman, but external genitals that appear like a male. The labia
The labia are part of the female genitalia; they are the major externally visible portions of the vulva. In humans, there are two pairs of labia: the ''labia majora'' (or the outer labia) are larger and thicker, while the '' labia minora'' are fo ...
fuse, and the clitoris enlarges to appear like a penis. The causes of this can be male hormones taken during pregnancy, congenital adrenal hyperplasia, male-hormone-producing tumors in the mother and aromatase deficiency.
=46, XY intersex
=
This condition used to be called "male pseudohermaphroditism". This is defined as incomplete masculinization of the external genitalia. Thus, the person has male chromosomes, but the external genitals are incompletely formed, ambiguous, or clearly female. This condition is also called 46, XY with undervirilization. 46, XY intersex has many possible causes, which can be problems with the testes and testosterone formation. Also, there can be problems with using testosterone. Some people lack the enzyme needed to convert testosterone to dihydrotestosterone
Dihydrotestosterone (DHT, 5α-dihydrotestosterone, 5α-DHT, androstanolone or stanolone) is an endogenous androgen sex steroid and hormone. The enzyme 5α-reductase catalyzes the formation of DHT from testosterone in certain tissues includ ...
, which is a cause of 5-alpha-reductase deficiency. Androgen insensitivity syndrome
Androgen insensitivity syndrome (AIS) is a difference in sex development involving hormonal resistance due to androgen receptor dysfunction.
It affects 1 in 20,000 to 64,000 XY ( karyotypically male) births. The condition results in the partial ...
is the most common cause of 46, XY intersex.
=True gonadal intersex
=
This condition used to be called "true hermaphroditism
True hermaphroditism, sometimes referred to as ovotesticular syndrome, is an intersex condition in which an individual is born with both ovarian and testicular tissue. Commonly, one or both gonads is an ovotestis containing both types of tis ...
". This is defined as having asymmetrical gonads with ovarian and testicular differentiation on either sides separately or combined as ovotestis. In most cases, the cause of this condition is unknown.
=Complex or undetermined intersex
=
This is the condition of having any chromosome configurations rather than 46, XX or 46, XY intersex. This condition does not result in an imbalance between internal and external genitalia. However, there may be problems with sex hormone levels, overall sexual development, and altered numbers of sex chromosomes.
Conditions
There are a variety of opinions on what conditions or traits are and are not intersex, dependent on the definition of intersex that is used. Current human rights based definitions stress a broad diversity of sex characteristics that differ from expectations for male or female bodies. During 2015, the Council of Europe, the European Union Agency for Fundamental Rights
The European Union Agency for Fundamental Rights, usually known in English as the Fundamental Rights Agency (FRA), is a Vienna-based agency of the European Union inaugurated on 1 March 2007. It was established by Council Regulation (EC) No 168/20 ...
and Inter-American Commission on Human Rights have called for a review of medical classifications on the basis that they presently impede enjoyment of the right to health; the Council of Europe expressed concern that "the gap between the expectations of human rights organisations of intersex people and the development of medical classifications has possibly widened over the past decade".
Medical interventions
Rationales
Medical interventions take place to address physical health concerns and psychosocial risks. Both types of rationale are the subject of debate, particularly as the consequences of surgical (and many hormonal) interventions are lifelong and irreversible. Questions regarding physical health include accurately assessing risk levels, necessity, and timing. Psychosocial rationales are particularly susceptible to questions of necessity as they reflect social and cultural concerns.
There remains no clinical consensus about an evidence base, surgical timing, necessity, type of surgical intervention, and degree of difference warranting intervention. Such surgeries are the subject of significant contention due to consequences that include trauma, impact on sexual function and sensation, and violation of rights to physical and mental integrity. This includes community activism, and multiple reports by international human rights and health institutions and national ethics bodies.
In the cases where gonads may pose a cancer risk, as in some cases of androgen insensitivity syndrome
Androgen insensitivity syndrome (AIS) is a difference in sex development involving hormonal resistance due to androgen receptor dysfunction.
It affects 1 in 20,000 to 64,000 XY ( karyotypically male) births. The condition results in the partial ...
, concern has been expressed that treatment rationales and decision-making regarding cancer risk may encapsulate decisions around a desire for surgical "normalization".
Types
* Feminizing and masculinizing surgeries: Surgical procedures depend on the diagnosis, and there is often a concern as to whether surgery should be performed at all. Typically, surgery is performed shortly after birth. Defenders of the practice argue that individuals must be clearly identified as male or female for them to function socially and develop "normally". Psychosocial reasons are often stated. This is criticised by many human rights institutions, and authors. Unlike other aesthetic surgical procedures performed on infants, such as corrective surgery for a cleft lip
A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The te ...
, genital surgery may lead to negative consequences for sexual functioning in later life, or feelings of freakishness and unacceptability.[Intersex Society of North America (24 May 2006)]
What evidence is there that you can grow up psychologically healthy with intersex genitals (without "normalizing" surgeries)?
. Retrieved 25 November 2006.
* Hormone treatment: There is widespread evidence of prenatal testing and hormone treatment to prevent or eliminate intersex traits,[Bioethics Forum blog – Preventing Homosexuality (and Uppity Women) in the Womb?](_blank)
, Alice Dreger
Alice Domurat Dreger () is an American historian, bioethicist, author, and former professor of clinical medical humanities and bioethics at the Feinberg School of Medicine, Northwestern University in Chicago, Illinois.
Dreger engages in academic ...
, Ellen K. Feder, Anne Tamar-Mattis
Anne Tamar-Mattis is an American attorney, human rights advocate, and founder of interACT (formerly Advocates for Informed Choice). She currently serves as interACT's Legal Director.
Career
Anne Tamar-Mattis spent six years as the Director of ...
(2010), at Hastings Center Bioethics Blog, retrieved 18 May 2012. associated also with the problematization of sexual orientation and gender non-conformity.
* Psychosocial support: All stakeholders support psychosocial support. A joint international statement by participants at the Third International Intersex Forum
The International Intersex Forum is an annual event organised, then later supported, by the ILGA and ILGA-Europe that and organisations from multiple regions of the world, and it is believed to be the first and only such intersex event.
Predec ...
in 2013 sought, amongst other demands: "Recognition that medicalization and stigmatisation of intersex people result in significant trauma and mental health concerns. In view of ensuring the bodily integrity and well-being of intersex people, autonomous non-pathologising psycho-social and peer support be available to intersex people throughout their life (as self-required), as well as to parents and/or care providers."
* Genetic selection and terminations: The ethics of preimplantation genetic diagnosis
Preimplantation genetic diagnosis (PGD or PIGD) is the genetic profiling of embryos prior to implantation (as a form of embryo profiling), and sometimes even of oocytes prior to fertilization. PGD is considered in a similar fashion to prenatal ...
to select against intersex traits was the subject of 11 papers in the October 2013 issue of the '' American Journal of Bioethics''. There is widespread evidence of pregnancy terminations arising from prenatal testing, as well as prenatal hormone treatment to prevent intersex traits. Behrmann and Ravitsky find social concepts of sex, gender and sexual orientation to be "intertwined on many levels. Parental choice against intersex may thus conceal biases against same-sex attractedness and gender nonconformity."
* Medical display. Photographs of intersex children's genitalia are circulated in medical communities for documentary purposes, and individuals with intersex traits may be subjected to repeated genital examinations and display to medical teams. Problems associated with experiences of medical photography of intersex children have been discussed[ p. 72.] along with their ethics, control and usage. "The experience of being photographed has exemplified for many people with intersex conditions the powerlessness and humiliation felt during medical investigations and interventions".[
p. 70.]
* Gender dysphoria: The DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatri ...
included a change from using gender identity disorder to gender dysphoria. This revised code now specifically includes intersex people who do not identify with their sex assigned at birth and experience clinically significant distress or impairment, using the language of disorders of sex development
Disorders of sex development (DSDs), also known as differences in sex development, diverse sex development and variations in sex characteristics (VSC), are congenital conditions affecting the reproductive system, in which development of chromo ...
.
See also
* Intersex Awareness Day
Intersex Awareness Day is an internationally observed awareness day each October 26, designed to highlight human rights issues faced by intersex people.
History
The event marks the first public demonstration by intersex people in North America ...
* Intersex people and military service
Military service of intersex people varies greatly by country. Some armed forces such as the Australian fully embrace intersex people in modern-day while others have vague rules or policies or treat the subject on a case by case basis, such as ...
* Sexual differentiation in humans
Sexual differentiation in humans is the process of development of sex differences in humans. It is defined as the development of phenotypic structures consequent to the action of hormones produced following gonadal determination. Sexual differenti ...
* Gynandromorphism
A gynandromorph is an organism that contains both male and female characteristics. The term comes from the Greek γυνή (''gynē'') 'female', ἀνήρ (''anēr'') 'male', and μορφή (''morphē'') 'form', and is used mainly in the field ...
* Endosex
An ''endosex'' person is someone whose innate sex characteristics fit normative medical or social ideas for female or male bodies. The word ''endosex'' is an antonym of ''intersex''.
Etymology and meaning
The prefix '' endo-'' comes from the An ...
* True hermaphroditism
True hermaphroditism, sometimes referred to as ovotesticular syndrome, is an intersex condition in which an individual is born with both ovarian and testicular tissue. Commonly, one or both gonads is an ovotestis containing both types of tis ...
* Androgyny
Androgyny is the possession of both masculine and feminine characteristics. Androgyny may be expressed with regard to biological sex, gender identity, or gender expression.
When ''androgyny'' refers to mixed biological sex characteristics in ...
References
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External links
{{Authority control
Intersex
Sex
Medical controversies