Intersexxed

Intersexxed
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This is the latest accepted revision , reviewed on 22 June 2022 .
Uncommon congenital variations of sex-associated characteristics
This article is about intersex in humans. For intersex in other animals, see Intersex (biology) .
  Legal prohibition of non-consensual medical interventions
  Regulatory suspension of non-consensual medical interventions
Parts of this article (those related to map) need to be updated . Please help update this article to reflect recent events or newly available information. ( May 2021 )
  Explicit protection on grounds of sex characteristics
  Explicit protection on grounds of intersex status
  Explicit protection on grounds of intersex within attribute of sex
Female congenital anomalies of the genitalia, including Intersex and DSD
Male congenital anomalies of the genitalia, including Intersex and DSD
Sexual orientations – Medicine, science and sexology
Intersex people are individuals born with any of several sex characteristics including chromosome patterns, gonads , or genitals that, according to the Office of the United Nations High Commissioner for Human Rights , "do not fit typical binary notions of male or female bodies". [1] [2]

Sex assignment at birth usually aligns with a child's anatomical sex and phenotype . The number of births with ambiguous genitals is in the range of 0.02% to 0.05%. [3] Other conditions involve atypical chromosomes, gonads, or hormones. [4] [5] 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. [6] [7] [8] 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%. [9] [10] A study published by Leonard Sax reports that this figure includes conditions which most clinicians do not recognize as intersex, and that in those "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%. [4] [11] [12]

Terms used to describe intersex people are contested, and change over time and place. Intersex people were previously referred to as " hermaphrodites " or "congenital eunuchs ". [13] [14] In the 19th and 20th centuries, some medical experts devised new nomenclature 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 ", "female pseudohermaphroditism ", or "male pseudohermaphroditism". [15] 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. [16] In biology, the term "hermaphrodite" is used to describe an organism that can produce both male and female gametes . [17] [18] Some people with intersex traits use the term "intersex", and some prefer other language. [19] [20] [ page range too broad ] In clinical settings, the term " disorders of sex development " (DSD) has been used since 2006, [21] a shift in language considered controversial since its introduction. [22] [23] [24]

Intersex people face stigmatization and discrimination from birth, or following the discovery of intersex traits at stages of development such as puberty . Intersex people may face infanticide , abandonment, and the stigmatization of their families. [25] [26] [27] Globally, some intersex infants and children, such as those with ambiguous outer genitalia, are surgically or hormonally altered to create more socially acceptable sex characteristics. However, this is considered controversial, with no firm evidence of favorable outcomes. [28] Such treatments may involve sterilization . Adults, including elite female athletes, have also been subjects of such treatment. [29] [30] Increasingly, these issues are considered human rights abuses , with statements from international [31] [32] and national human rights and ethics institutions (see intersex human rights ). [33] [34] Intersex organizations have also issued statements about human rights violations, including the 2013 Malta declaration of the third International Intersex Forum . [35] In 2011, Christiane Völling became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention. [36] In April 2015, Malta became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people. [37] [38]
There is no clear consensus definition of intersex and no clear delineation of which specific conditions qualify an individual as intersex. [39] The World Health Organization's International Classification of Diseases (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). [40]

A common adjective for people with disorders of sex development (DSD) is "intersex". [1]

In 1917, Richard Goldschmidt created the term "intersexuality" to refer to a variety of physical sex ambiguities. [15] However, according to The SAGE Encyclopedia of LGBTQ 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. [41]

According to the UN Office of the High Commissioner for Human Rights:

Intersex people are born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies. Intersex is an umbrella term used to describe a wide range of natural bodily variations. [2]
Some intersex organizations reference "intersex people" and "intersex variations or traits" [42] while others use more medicalized language such as "people with intersex conditions", [43] or people "with intersex conditions or DSDs (differences of sex development)" and "children born with variations of sex anatomy". [44] In May 2016, interACT published a statement recognizing "increasing general understanding and acceptance of the term 'intersex'". [45]

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. [7] [46]

Research on 202 respondents by the Lurie Children's Hospital , Chicago, and the AIS-DSD Support Group (now known as InterConnect Support Group) [47] 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. [48] The hospital reported that the use of the term "disorders of sex development" may negatively affect care. [49]

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". [50] Participants who were members of support groups were more likely to dislike the term. [50] 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. [51]

Historically, the term "hermaphrodite" was used in law to refer to people whose sex was in doubt. The 12th-century Decretum Gratiani states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails" ("Hermafroditus an ad testamentum adhiberi possit, qualitas sexus incalescentis ostendit."). [52] [53] Similarly, the 17th-century English jurist and judge Edward Coke (Lord Coke), wrote in his Institutes of the Lawes of England 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." [54] [55]

During the Victorian era , medical authors attempted to ascertain whether or not humans could be hermaphrodites, adopting a precise biological definition for the term, [56] and making distinctions between "male pseudohermaphrodite", "female pseudohermaphrodite" and especially " true hermaphrodite ". [57] These terms, which reflected histology (microscopic appearance) of the gonads , are no longer used. [58] [59] [60] Until the mid-20th century, "hermaphrodite" was used synonymously with "intersex". [61] Medical terminology shifted in the early 21st century, not only due to concerns about language, but also a shift to understandings based on genetics . [ citation needed ]

The Intersex Society of North America 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. [62]

Estimates of the number of people who are intersex vary, depending on which conditions are counted as intersex. [4] The now-defunct Intersex Society of North America stated that:

If you ask experts at medical centers how often a child is born so noticeably atypical in terms of genitalia that a specialist in sex differentiation is called in, the number comes out to about 1 in 1500 to 1 in 2000 births [0.07–0.05%] . But a lot more people than that are born with subtler forms of sex anatomy variations, some of which won't show up until later in life. [63]
Anne Fausto-Sterling and her co-authors broadly said in 2000 that "[a]dding 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"; [10] [9] these publications have been widely quoted by intersex activists. [64] [65] [66] 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 (LOCAH) which may be asymptomatic but can present after puberty and cause infertility. [67]

In response to Fausto-Sterling, Leonard Sax estimated that the prevalence of intersex was about 0.018% of the world's population, [4] 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. [4]

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. [68] 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". [68] A 2018 review reported that the number of births with ambiguous genitals is in the range of 0.02% to 0.05%. [3]

The figure of 1.7% is still maintained by Intersex Human Rights Australia "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. [69]

The following summarizes prevalences of traits that have been called intersex:

Prevalences of specific conditions can vary across regions. In the Dominican Republic , 5-alpha-reductase deficiency is not uncommon in the town of Las Salinas , resulting in social acceptance of the intersex trait. [88] 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. [89]

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. [90] He also recounted the lives of Diophantus of Abae and Callon of Epidaurus . [91] Ardhanarishvara , an androgynous composite form of male deity Shiva and female deity Parvati , originated in Kushan culture as far back as the first century AD. [92] A statue depicting Ardhanarishvara is included in India's Meenakshi Temple ; this statue clearly shows both male and female bodily elements. [93]

Hippocrates ( c. 460 – c. 370 BC Greek physician) and Galen (129 – c. 200/216 AD Roman 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". [94] Pliny the Elder (AD 23/24–79) the Roman naturalist described "those who are born of both sexes, whom we call hermaphrodites, at one time androgyni " (from the Greek andr- , "man," and gyn- , "woman"). [95] Augustine (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". [94]

In medieval and early modern European societies, Roman law , post-classical canon law , and later common law , 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. [96] The 12th century Decretum Gratiani states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails". [97] [98] [99] The foundation of common law, the 17th Century Institutes of the Lawes of England described how a hermaphrodite could inherit "either as male or female, according to that kind of sexe which doth prevaile." [100] [55] Legal cases have been described in canon law and elsewhere over the centuries.

Some non-European societies have sex or gender systems that recognize more than the two categories of male/man and female/woman. Some of these cultures, for instance the South-Asian Hijra communities, may include intersex people in a third gender category. [101] [102] Although–according to Morgan Holmes –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. [103]

During the Victorian era , medical authors introduced the terms " true hermaphrodite " 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. [104]

The term "intersexuality" was coined by Richard Goldschmidt in 1917. [105] The first suggestion to replace the term "hermaphrodite" with "intersex" was made by Cawadias in the 1940s. [61]

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. [106] An 'optimal gender policy', initially developed by John Money , stated that early intervention helped avoid gender identity confusion, but this lacks evidence. [107] Early interventions have adverse consequences for psychological and physical health. [34] 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. [108]

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. [109] In 2011, Christiane Völling became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention. [36] In April 2015, Malta became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people. [37] Many civil society organizations and human rights institutions now call for an end to unnecessary "normalizing" interventions, including in the Malta declaration . [110] [1]

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 Office of the United Nations High Commissioner for Human Rights and the World Health Organization (WHO). These developments have been accompanied by International Intersex Forums and increased cooperation amongst civil society organizations. However, the implementation, codification, and enforcement of intersex human rights in national legal systems remains slow.

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. [25] [26] Abandonments and infanticides have been reported in Uganda , [25] Kenya , [111] South Asia , [112] and China . [27]

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. [113] [114] 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. [115] 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 natio
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