• Sexual Health

What Is Intersex?

So, what is intersex?

Intersex is an umbrella term used to categorize various reproductive and sexual anatomy differences that don’t fit the usual male or female definitions. In short, intersex individuals may have chromosomes, genitals, or internal reproductive organs that don’t fit into the typical male or female category or may possess characteristics of both male and female sexes.

Intersex, by definition, is when someone generally appears to be one sex but has the dominant anatomy of the other sex or when someone is born in between the typical male and female sexes. An example of this would be a female-presenting person having mostly male anatomy. Another example of someone born intersex is someone born with an in-between presentation of male and female genitals, such as someone born with a larger-than-usual clitoris and without a vaginal opening or someone who has been born with a scrotum that is divided into a labia-like form. A person may also be born with mosaic genetics or cells with XX and XY chromosomes. 

While intersex is usually detected and assigned at birth, intersex anatomy isn’t always present then. Sometimes a person must reach the age of puberty before discovering they’re intersex. Some people may not even discover that they’re intersex until adulthood, when they discover that they’re infertile. In rare instances, intersex people are only diagnosed after they have passed away and are discovered through an autopsy. 

It's important to note that being intersex is not a disease, disorder, or condition.

Sex vs. Gender vs. Gender Identity 

Sex and gender are two terms often used interchangeably, but these two terms are not the same. Sex and gender have pretty stark differences. There’s also gender identity. But what are the differences between these three terms? 

You might be wondering what intersex gender is or what the gender of an intersex person would be, but it’s not as black and white as sex or gender. The gender an intersex person identifies as depends on the specific individual and what they feel like in the face of many, many physical, social, and mental details, both those that "conform to the norm" and those that don't. Like anyone else, intersex individuals are free to identify as a range of gender identities, from male, female, nonbinary, and other genders.

Intersex Causes

Being intersex isn’t common. It’s estimated that around 2% of individuals worldwide fit into the intersex category. Of those individuals, 1 in 100 Americans have traits classified as intersex. There are no exact causes known for being intersex. Some characteristics can be inherited through genetics or passed down from one generation in a family to the next. 

Some factors that may cause intersex to occur in an individual include: 

Intersex Symptoms 

Being intersex was once considered a sexual development disorder, but it is neither a disorder, condition, or disease. Intersex individuals don’t require special treatments or care. However, some intersex individuals may choose to have gender affirmation surgery, particularly if their gender doesn’t match the one they were assigned at birth. Gender affirmation surgery is a personal choice and is not something that needs to be done. 

Intersex individuals may have one or more of the following areas affected: 

Intersex can occur in around 40 different ways, affecting individuals differently. The more common intersex traits occur when a combination of chromosomes happens or when there are mixed genitals and reproductive organs.

Intersex Surgeries 

Intersex surgeries are not necessary. Some individuals may choose to receive them to better fit the gender they identify as. Due to this, they are known as non-lifesaving procedures aimed at changing genital appearance or altering the reproductive system. 

There are many types of surgeries, including: 

Risks and Complications 

It’s important to understand the consequences of intersex surgeries, specifically, those performed on infants. Many intersex surgeries involve lifelong physical and emotional concerns, including reduced sexual function and high complication rates. Additionally, some surgeries risk UTIs developing throughout the individual’s life. 

The United Nations considers the practice of intersex surgery to violate human rights, especially when performed without an individual’s consent.

Most surgeries are offered to parents with children under two. Some doctors accept these surgeries, but since children cannot consent to the surgery, it’s often at the expense of allowing a person later to make an important decision regarding their own body. 

Intersex usually carries no risks, so getting the surgery is completely optional. Intersex differences are healthy, and surgery is generally required only when an infant cannot urinate due to these differences. However, this is rare. 

Pregnancy Considerations

Many people who are intersex or have intersex children wonder about reproduction and pregnancy rates. Whether an intersex person can get pregnant depends upon the person’s body parts. For example, if an intersex person has a penis and sperm-producing testicles, they may be able to cause pregnancy. Likewise, if an intersex person has a uterus, they may be able to become pregnant. 

While many intersex differences may result in infertility, not all do. However, making the decision to have surgery performed on an intersex child who cannot consent to the surgery themselves may render them infertile.

Supporting Intersex Differences 

If you know someone who is intersex, it’s important that you understand how to accept and support them. Intersex happens on its own and is not something that can be helped, nor should it be considered a disease. Instead of alienating those with intersex differences, you should educate yourself regarding the specific intersex differences that the specific individual has. Education on the subject can help prevent you from saying something that may be offensive or triggering to the intersex individual. Additionally, being self-aware of your attitude regarding sex and gender is just as important.

If the intersex individual you know is your child or someone else’s child, you must familiarize yourself with how to discuss sex and sexuality in an age-appropriate manner. You’ll also want to do your part to ensure that the intersex person is not discriminated against or teased about their differences.

Finally, it’s important to remember that most intersex individuals are happy with their differences and do not wish to have surgery. Do not make assumptions based on their sex or gender; allow them to identify with their choices. If you would like to learn more about how you can support these individuals, there are support groups available to intersex individuals and their loved ones.

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Intersex Babies: Boy or Girl and Who Decides?

Parents want children's genitals 'fixed,' but surgery is irreversible.

March 17, 2011— -- Jim Bruce was born with XY male chromosomes but ambiguous genitals. Doctors couldn't be sure if he had a large clitoris or a small penis and were convinced he could never live a "satisfactory life" as a man.

So shortly after his birth in 1976, Bruce's external organ and testes were surgically removed and he was raised as a girl.

He struggled for years, preferring "rough and tumble" play and being attracted to girls.

"I was unhappy, but it was really difficult to ask questions," said Bruce, now a 34-year-old writer from California.

When he was 12, Bruce was given female hormones so his body would feminize. Then, at 18, he prepared for a vaginoplasty -- "designed to allow me "to have sex with my husband."

But he knew something was wrong and, battling depression, sought his medical records when he was 19.

"I knew that I wasn't a girl," he said.

What Bruce discovered was horrifying. "I was sterilized at birth -- and no one ever told me," he said.

An estimated 1 in 2,000 children born each year are neither boy nor girl -- they are intersex, part of a group of about 60 conditions that fall under the diagnosis of disorders of sexual development (DSD).

Once called hermaphrodites, from the handsome Greek god who had dual sexuality, they are now known as intersex.

Standard medical treatment has been to look at the genitals, determine the gender and then correct it surgically.

But now, many are challenging the ethical basis of surgery, knowing that gender identity is complex, and doctors can sometimes get it wrong, not knowing how a child will feel about their gender assignment when they grow up.

Advocates argue that surgery is irreversible and can have tragic consequences. In Bruce's case, he has been rendered infertile.

In some surgeries on virilized girls with ambiguous genitalia, removing sensitive tissue and vessels can ultimately rob them of sexual sensation as adults.

Bruce was born with a DSD that prevented his body from producing enough testosterone to properly develop his genitals.

After discovering the truth, he transitioned back to a man, taking testosterone shots and having his breasts removed.

Today Bruce works with Advocates for Informed Choice , a legal group to that promotes the civil rights of those who are born with sex variations.

"It wasn't that long ago, and parents were often led to believe they were doing the best thing for the child," he said. "They still don't know anything now, and they don't do any follow up."

At first he blamed his parents, but later realized, "they were only kids, 27 and 29, and they were scared. I never had any doubt my parents loved me very much."

As little as a decade ago, the medical community thought of gender as a slate that could be erased and then redrawn.

Today, gender identification is still not well understood, but experts say that when sex cannot be determined, it's better to use the best available information to assign gender, then to wait and monitor the child's psychological and physical development before undertaking surgery, if at all.

Waiting until puberty also allows the child to participate in the decision.

"Our chromosomes don't tell us who we are," said Dr. Arlene Baratz , a Pittsburgh breast radiologist who has two intersex daughters. "We expect XX is pink and a girl and XY is blue and a boy, but we know from children with gender identity conditions that is not always the case, even when their bodies are perfectly typical."

Assign Gender, But Wait for Surgery

"Today, we anticipate how the child will feel as an adult and what they feel inside," said Baratz. "That is called gender identity and the gender role is how we live in society as a man or a woman. So gender assignment is aimed at putting gender identity and role in sync with each other as the child grows older."

Baratz's daughter Katie was born with male chromosomes, but has a DSD called complete androgen insensitivity syndrome (cAIS). Because her androgen receptors are faulty, Katie developed female characteristics.

She has a vagina, but no uterus or ovaries. When she was 6, doctors discovered small testes in a hernia sac.

Today, at 26, Katie is married and in medical school hoping to one day be a child psychiatrist. Though she is infertile, she hopes to become a parent through adoption or gestational surrogacy.

"These girls look completely female and they are girls," said her mother. When these cAIS babies are gender assigned as female, 99 percent of them go on to feel like women when they grow up.

But in a similar disorder, partial androgen insensitivity syndrome (pAIS), doctors can't always be sure. Because they have been affected by some androgen, about 50 percent of them do not accept the gender that is assigned to them.

Baratz, who works with advocacy groups like the Accord Alliance pushes for more support for parents and children dealing with intersexuality.

"They are made to feel ashamed," she said. "It would be good for families if someone said there may be an issue, but there is support for this. They are made to feel, even by the medical community, as something shameful."

"A lot of urologists argue strongly for surgery," she said. "There is a place for waiting and allowing children to have some voice in the decision and wait for long term effects or until something better is available. It's important to talk to them about what we don't know."

Stanford University has set up a multidisciplinary committee to explore these ethical issues and hopes soon to launch a DSD clinic.

Dr. Hsi-Yang Wu, a pediatric urologist at Stanford, said he sees a case of intersex about "once or twice a year," but endocrinologists may consult with two or three families a month.

"The surgical approach has become much more nuanced in terms of who needs surgery," said Wu. "Early on, we assumed all children with DSD got surgery. But things have changed."

The spring issue of Stanford Medicine magazine describes a baby with a potentially life-threatening form of the endocrine disorder, congenital adrenal hyperplasia.

Born with XX female chromosomes, the baby had ovaries, a uterus and fallopian tubes, a clitoris that looked more like a penis and partially fused labia.

The condition accounts for about 60 percent of all DSDs. The adrenal glands lack an enzyme to make the hormones cortisol and aldosterone, and so the girls' bodies create more androgen.

As a result, their genitals, and some say their brains, are masculinized and they must take daily hormone medication to stay alive.

At the age of 6 months, the baby had surgery to reduce the size of her clitoris and open her labia. She'll need another one at puberty to widen the vaginal canal.

Wu said doctors no longer use a surgical technique that pulls the clitoris under the pubic bone, which can cause painful orgasms in adulthood. He uses a nerve-sparing technique that removes the erectile portion of the clitoris.

"In this kind of case, she didn't fit into the typical DSD classification and it made it challenging," he said. "We try to predict what the gender identity will be, and three or four years later, the child psychologist can give us some kind of idea."

Parents are also confused. "It's so hard to accept that my child will look different to anyone who changes the diapers," said Wu. "Some parents are so torn by the fear that they will make the wrong choice and mess up the child forever."

Hormones are identical in children until they reach puberty, but by the time they are about 12 their bodies can change.

"The thing we worry about is if something starts to kick in when they age and they are not the sex we raised the child," he said. "What do we do then?"

Who Protects the Child's Rights?

Anne Tamar-Mattis, executive director of Advocates for Informed Choice , worries about the legal side of this complicated issue, especially when it involves sterilization without a child's consent.

"We don't weigh in on what medical decisions people should make," she said. "We weigh in on children's rights. If the decision involves sterilization, the child has a right to court over sight."

And when parents are making these complex decisions to remove the child's reproductive organs, they must be fully informed. Often, they are not, she said.

Katrina Karkazis, senior research scholar at Stanford's Center for Biomedical Ethics and author of "Fixing Sex: Intersex, Medical Authority and Lived Experience," agrees that "the child can't speak for him or herself."

The American Academy of Pediatrics' Consensus of Care was established in 2006 to address treatment of intersex disorders.

"Everyone agrees there must be gender assignment," she said. "In a good scenario, the physician makes a decision with a lot of reflection and without rushing in to anything and in consult with the parents."

The number of children who don't accept their gender assignment is small, according to Karkazis. "What's missing is these families and kids don't get the appropriate social and psychological support."

She recommends that doctors "check in" with the child over his or her life span and "find out what they are feeling."

Behavior is not always the best indicator.

"Pay attention to what child a child is telling you -- there may be a switch which needs to be evaluated with expertise," she said. "Plenty of kids go through phases -- I am a girl or I am a boy -- and it ends after a year. But one thing that is irreversible is surgery."

"Once you've removed the tissues, you can't put them back," she said. "It's infinitely more complicated and for the most part, you cannot replace a phallus."

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Intersex Society of North America

The Intersex Society of North America closed its doors and stopped updating this website in 2008. ISNA’s work is continued by interACT: Advocates for Intersex Youth , who proudly preserves this website as a historical archive. For current information, links to intersex support groups, and to connect with intersex advocates, please head to interACT: Advocates for Intersex Youth .

gender assignment of intersex

# What does ISNA recommend for children with intersex?

After years of consultation with people with intersex conditions, their parents, their healthcare providers, and others, the following Patient-Centered Model is what ISNA recommends.

Does this mean ISNA recommends “doing nothing”? Not at all. Please re-read the above, and if you’d like more information about how our recommendations differ from the traditional concealment-centered model, check out our chart called Shifting the Paradigm of Intersex Treatment .

← Turner Syndrome Does ISNA think children with intersex should be raised without a gender, or in a third gender? →

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The birth of a new baby is one of the greatest wonders of nature and one of the most exciting events known to man. The first question that is usually posed by the mother or father is “is it a boy or a girl?”; without this information the new parents cannot even formulate the second question which is usually “is he/she alright?”. It is no wonder that the birth of a child with complex genital anomalies where the sex of rearing is uncertain at birth, presents difficult clinical and ethical issues.


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Over the past few years, a number of justified concerns have been raised about the long term outcome of such infants and this has led to a comprehensive reappraisal of clinical management. While the current debate among clinicians, psychologists, ethicists, sociologists, historians, and patient support groups has long been overdue, the contribution of most of the participants has been largely based on personal experience and clinical evidence that often suffers from a substantial amount of selection bias and group based generalisation. There is a danger, however, that this debate may lead to a hiatus in providing optimal clinical care to the child and the child’s family. Because sex, gender, and sexuality are at the very core of individual identity in most cultures, it is difficult to dislodge our ideas and, more so, our feelings about them, without a clear understanding of these issues. Delayed gender assignment of a newborn with complex genital anomalies is only one of the many issues under the spotlight and has often been muddled with another important question that relates to the timing of reconstructive surgery.

In the first half of the twentieth century, the term gender was used to refer to those sexual behaviours that were more associated with men and women. Nowadays, gender relates to the social and cultural organisation of the sexes. Sex roles and gender roles used to be interchangeable terms but, increasingly, there is a difference between biological sex and social (gender) relations. It is one thing to have a vulva, vagina, clitoris, breasts, ovaries, 46XX karyotype, etc, but it may be quite another thing being female, feminine, or a woman. Unlike the sex categories, male and female, gender has several aspects: gender assignment, gender role, gender identity, gender attribution, and sexuality. In most societies, gender assignment occurs at birth, long before we have a say in the matter, marking the beginning of the process of gender socialisation. The process of gender socialisation also includes society’s expectations of how males or females should behave, as expressed in their gender role behaviour. Gender identity is distinct from gender role behaviour and refers to the individual’s perception of one’s own gender and how it conforms to the male or female gender role in society. Gender attribution is what we all do when we meet someone and want to decide whether they are a man or a woman. This is often based on obtaining a number of cues which are symbolic manifestations of gender and that have traditionally included clothing, mannerisms, physical appearance, gait, and occupational choice. Finally, sexuality refers to erotic desires, sexual practices, or sexual orientation. In the Western culture, individuals are often socially identified as homosexuals or heterosexuals as if a person’s sexual orientation encapsulates the total personality and identity. For most people, their gender identity, gender role, and the symbolic gender manifestations are congruent and, in addition, they will be sexually attracted to the opposite sex. However, it is also possible that a man may have gender manifestations that do not completely converge with his male gender identity and remains sexually attracted to the opposite sex; of course, a number of other permutations may also exist. Some aspects of gender, such as role, assignment, the symbolic manifestations, as well as the different types of sexuality, may differ markedly from one society to another and continue to evolve within respective societies. In some Western cultures, the distinction is becoming less absolute and it may be better to consider these aspects as a continuum, with female characteristics at one extreme and male ones at the other.


John Money proposed that we are born tabula rasa and our gender identity was programmed into us during the first few years of life, mainly through parental/social conditioning and reinforcement of gender role behaviour. 1 It is possible that this original hypothesis may have contributed towards the rationale for performing early gender assignment and surgery in children presenting with complex genital anomalies at birth. This theory was famously challenged through the follow up of the John v Joan case and by patient support groups, as well as subsequent research on long term outcomes. 2– 4

The development of gender identity is the result of a complex interaction between genetic, prenatal, and postnatal endocrine influences and postnatal psychosocial and environmental experiences. However, Money’s concept of a “critical period” for gender identity formation has remained a theme in current gender development research. Just as a child’s cognitive and social development occurs in stages during the first five critical years of life, gender identity development is also often viewed according to age-stage/cognitive development theory. 5

Gender development research has focused on elements of gender identity formation such as gender knowledge, self perception, preferences (toy, playmate), and gender role behaviours. By the end of the first year of life, infants are already able to discriminate between the sexes, and some may be able to display sex related toy preferences. By 2–3 years of age children are able to correctly label themselves and others according to gender. By the age of 3 years, preference for one sex role has emerged with the child having a clear sense of whether he/she is a boy or girl. Children fix on cues such as clothing and hair in gender labelling exercises; even when genital cues are available they are used far less to make categorisation decisions than these other cues, at least until the age of 8 years or so, possibly reflecting insufficient biological understanding of gender differences.

By the age of 5 years, children learn that gender remains stable over time, becoming preoccupied with categorical differences between males and females. However, it is not until children have mastered the concept that gender remains constant (despite superficial changes in appearance), at the age of between 5 and 7, that many argue is when a gender identity has been fully attained. Theorists have suggested that once “gender constancy” has been mastered, this becomes a motivator to shaping sex appropriate gender behaviour. 5


There are scarce data on how children with complex genital anomalies perceive their genitals and how this relates to their gender development. Long term outcome case studies of such boys indicate that male gender identity does develop in the absence of gender specific genitalia. 6 A systematic examination of the relation between genital appearance and gender identity in a group of girls with congenital adrenal hyperplasia, showed a link between atypical gender identity and prenatal androgen exposure, but not with the degree of virilisation. 7 Taken together, this research suggests that genital appearance may not be as crucial a determinant in gender identity as once thought, although further research is necessary to clarify this observation.


In contemporary European (and North American) cultures, sex and gender have traditionally been based on binary opposites—male and female, man and woman, homosexual and heterosexual. There are a number of other cultures where there is greater gender diversity and gender does not always neatly divide into male and female. In these cultures, this gender variance has often been idealised and romanticised by many in the Western world. However, in such gender diverse cultures, the diversity always exists against a background of what it means to be male or female in that particular society. Social attitudes do vary within these cultures, as well as between them, and are complex. 8 Nowadays, in most societies where these cultures exist, attitudes towards gender diversity include a combination of awe, fear, respect, ridicule, disgust, dismay, pity, and bemusement. Even when gender diversity is associated with ritual powers, such as on the Indian subcontinent, social interactions can often be hostile. Such attitudes and restricted occupational opportunities have led to segregation and development of subcultures and social communities. The degree to which this occurs probably depends on the size of the population; there is evidence to suggest that the acceptance of alternative genders may be easier in smaller, less socially specialised populations. 8


The optimal policy for gender assignment needs to be a balance between our knowledge of the effect of the biological determinants that influence long term gender identity (that is, prenatal androgens) and the power of the affected individual in making decisions about his or her own outcome. Current evidence suggests that sex reassignment in adulthood is a relatively rare phenomenon and occurs rarely in children with undermasculinised boys 9– 11 and masculinised girls 12, 13 and when it does occur, it seems to occur most often in conditions associated with a defect in androgen biosynthesis which may result in spontaneous masculinisation at puberty. 14, 15 Research in women with congenital adrenal hyperplasia suggests that although prenatal androgen excess may often lead to a masculinised gender role behaviour, this does not influence gender identity unless the affected individual presents late. 7, 12, 13, 16– 19 Recurrent genital reconstructive surgery may be associated with long term dissatisfaction with sexual function and an altered perception of body image, and it is possible that this may, itself, lead to a change in gender identity from female to male or vice versa. 20 It is also possible that suboptimal medical therapy and a lack of knowledge about one’s condition may have a greater effect on long term functional outcome than the original anatomic disorder. Genital masculinisation is a poor predictor of the masculinisation of the brain; not only is the correlation between these two poor, the underlying mechanisms are different whereby genital development is dependent on testosterone and dihydrotestosterone, while gender role behaviour is dependent on testosterone and oestradiol exposure. 21 Although the John v Joan case has been instrumental in challenging the management of children with complex genital anomalies, this single, rather atypical case of gender identity change from female to male gender may have over-exaggerated the role of prenatal hormones in the development of gender identity in all cases of complex genital anomalies. 21 The gender assignment of the newborn with complex genital anomalies should not, therefore, just be based on a simple extrapolation of future gender role behaviour from the appearance of the genitalia at birth, but on the best prognosis for future psychosocial and psychosexual function, taking into account the clinical presentation of the child, details of the clinical syndrome, as well as the possible effects of prenatal steroid exposure. Given that gender role behaviour is a continuum, the possibility of altered gender role behaviour in the longer term should be recognised and discussed with the family, but it should not play a major part in influencing gender assignment at birth.


Although genital anomalies such as hypospadias may have a birth prevalence of around 1 in 300 births, 22 it is estimated that the birth prevalence of complex genital anomalies where gender assignment may be difficult at birth is about 1 in 4500 births. 23 However, it is unclear how this figure has been derived, given that genital ambiguity depends on the clinical experience of the observer. Infants with complex genital anomalies due to 46XY undermasculinisation, but not those that result in completely female external genitalia (complete androgen insensitivity, testosterone biosynthetic defects) should usually be reared as boys. Although some of these infants will have dysgenetic gonads, a biosynthetic defect of testosterone production, or partial androgen insensitivity, in most of these cases the underlying biological abnormality remains unclear. These children will probably require a repair of the hypospadias, orchidopexy, and an evaluation of testicular function. In those cases where the testes are rudimentary and non-functional, it is advisable that they are removed as early as technically feasible. The next common clinical scenario is one of the masculinised, 46XX infant (for instance, congenital adrenal hyperplasia), and it is usually appropriate to raise these infants as girls. However, the decision in the severely masculinised infant may be influenced by factors such as a delay in diagnosis, social bias, and the “premium” on male rearing in certain communities. A modest degree of clitoral enlargement or genital ambiguity may not require surgical correction or aggressive suppression of serum androgen levels, and the emphasis should always be on long term functional outcome rather than cosmetic appearance. The need for an early genitoplasty in girls with marked clitoromegaly requires careful discussion and this should be documented in the medical records of the child. The surgeon should be allowed to retain the option of late reconstructive surgery for genitoplasty as well as vaginoplasty in those cases where it is likely that early surgery is more likely to be associated with long term adverse morbidity rather than improved functional outcome. Complex genital anomalies can also occur in children with gonadal dysgenesis associated with a 45XO/46XY karyotype, and as most of these affected infants have a varying level of undermasculinised external male genitalia, it would be appropriate to raise most of these cases as boys. Although prenatal screening suggests that the incidence of 45X/46XY may be about 1 per 15 000 pregnancies, 90% of the offspring are phenotypically male. 24 Gonadal differentiation in some of these cases may be mixed, and these infants would need to be approached as a true hermaphrodite where the infant may be 46XX, 46XY, or 46XX/46XY and possesses both ovarian and testicular tissue. 25 This is a very rare condition estimated to have a population prevalence of about 15 per million inhabitants. 26 As the reconstruction of the male genitalia had often been unsatisfactory in the past, gender assignment in these children had been biased towards the female sex. However, advances in reconstructive techniques for severe hypospadias and micropenis and concurrent reports of adequate long term satisfaction with sexual function in a substantial proportion of adults with micropenis is now leading to a reconsideration of this deep seated rationale. 27, 28 Gender assignment in these cases will, therefore, be guided by the potential for future sexual and reproductive function and the potential for tumour development. Even in these complex cases, an adequate knowledge of the pathology and its long term outcome is sufficient to decide on gender assignment soon after birth.

Most clinicians agree that the goals of management in a newborn with complex genital anomalies should be the facilitation of a stable gender identity, provision of psychological support to the family, age appropriate education about the disorder, optimal sexual function, optimal body image, potential for reproduction, and minimal medical and surgical intervention. However, it is unrealistic to develop group based gross generalisations, especially as the priority assigned to these usual goals of management by the child, family, and carers will vary from case to case. A third gender is not a feasible option considering that in most cultures around the world, gender variants are not treated as equals and that the nations of the industrialised society are ill equipped to cope with this concept. Unless we decide that all individuals with complex genital anomalies live socially as “intersex people”, this is not a simple solution and may be considered as “sweeping the problem under the carpet”. Considering that, in most infants, the long term gender of rearing is not particularly disturbed, the attention needs to move away from the debate on delayed gender assignment to optimising surgical and medical intervention. Given that there is some evidence that early and multiple surgical interventions may be associated with adverse long term functional outcome, 29, 30 and there is little published evidence favouring these regimens, a careful multidisciplinary and fully informed discussion needs to be performed with the parents of an infant where surgery is contemplated. 31 Surgery should only be performed by surgeons trained and experienced in genital reconstructive surgery and who are part of a multidisciplinary network concerned with a holistic management of the family and their child with complex genital anomalies. While polarised views exist about early versus late surgery in the clinical professions, each child and the respective family should be treated individually and the clinicians should refrain from imposing their own subjective views. The parents need to be provided with current objective evidence of effectiveness of the clinical interventions in optimising long term outcome, and they should be made aware of current knowledge about gender development. Irrespective of the parents’ decision, health professionals should be prepared to provide the appropriate psychological, surgical, and medical support to them as well as their affected child. Sufficient resources need to be available to support clinical networks that encourage these activities, and which can audit these processes and develop suitable guidelines, so that we will not still be in the same position in another three to four decades.


SM is supported through the Scottish Audit of Genital Anomalies, a three year national project funded by NHS Quality Improvement Scotland.

This paper is dedicated to the memory of Sita Picton, Clinical Psychologist at the Royal Hospital For Sick Children, Yorkhill, Glasgow.

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'You can't undo surgery': More parents of intersex babies are rejecting operations

Josh, Ori and Kristina Turner at their home outside Seattle.

Kristina Turner will never forget the moment doctors at a hospital in Washington state told her something was different about her baby. Shortly after Ori was born in 2007, the medical staff noticed that the infant had abnormal genital swelling. Other than that, doctors assured Turner, everything was fine.

“They identified Ori as being female and told us we had a happy, healthy baby, and we went on our way,” Turner told NBC News.

But as a mother, Turner recalled, “I kind of knew something was different.”

A specialist later told Turner, a massage therapist, and her husband, Josh, a construction worker, that their infant had a rare intersex condition called partial androgen insensitivity syndrome with mosaicism. The condition caused Ori to have both XX chromosomes and XY chromosomes and genitalia that doctors did not consider clearly “male” or “female.”

Ori was perfectly healthy, but Turner said surgeons pressured her to agree to cosmetic surgery to make Ori appear more clearly female. She immediately refused.

“Intersex” is an umbrella term for people whose bodies do not match the strict definitions of male or female. Dozens of intersex variations exist, affecting the reproductive organs in ways that may or may not be visible. While the Trump administration seeks to permanently identify people as “male” or “female” based on their physical appearance at birth — a leaked draft proposal was sharply criticized by LGBTQ advocates this week — at least one in 2,000 people are born with atypical genitalia because of one of these conditions, according to Human Rights Watch, an international research and advocacy group.

gender assignment of intersex

Raising the world and an intersex child

“Gender normalizing” surgeries have been performed on intersex babies and children since at least the 1950s, often in secrecy, without ever telling the children. In the following decades, some people who underwent these surgeries as children began to speak out against them as human rights violations. Some said they had been assigned the wrong gender, while others had endured severe complications, including sexual dysfunction and infertility.

As their stories piled up, advocacy groups began calling for better education and support for parents of intersex children, as well as for limits on these types of operations. The advocates do not oppose surgery for intersex people in general, but they believe that if the goal is more cosmetic than medical, it’s a choice children should be allowed to make for themselves when they’re older.

This view is gaining traction. Three U.S. surgeons general, the United Nations, the World Health Organization, Physicians for Human Rights, the American Academy of Family Physicians , Human Rights Watch and Amnesty International have condemned medically unnecessary surgery on these children. In August, California became the first state to pass a resolution condemning the operations, though they are still legal there.

gender assignment of intersex

NBC OUT 'A baby cannot provide ... consent': Calif. lawmakers denounce infant intersex surgeries

But within the medical community — and within support groups for these children — opinion is not unanimous. The Societies for Pediatric Urology, which represents the physicians who treat these patients, strongly disagreed with the California legislation. The organization believes parents should have the option of choosing surgery for their baby if they believe it’s best for the child’s long-term physical and mental health.

In the absence of clear guidance, hundreds of parents in the U.S. each year face a decision that will have a lifelong impact on their child. There are no official figures, but experts believe that while more parents are deciding against surgery, they are still in the minority.

Dr. Yee-Ming Chan, a pediatric endocrinologist at Harvard Medical School, said there is little research to help parents decide.

“There’s certainly stories of individuals who found it distressing to have ambiguous genitalia, but we don’t know how representative that is,” Chan said. “So I think there really is a ton of unanswered questions.”


Turner, who lives an hour and a half north of Seattle, faced criticism from some extended family members who believed she was placing an enormous burden on her newborn in choosing not to have the surgery.

“But I just completely disagreed,” Turner, 35, said, “because I was like, ‘You can’t undo surgery.’”

Ori Turner

Since she couldn’t predict the gender her child would embrace, she said, it didn’t seem like her decision to make. And she recalled that none of the doctors could tell her how the surgery, which involved altering sensitive tissue, might affect the baby as an adult.

Based on the advice of medical professionals, Turner and her husband decided to raise Ori as a girl, because they were told that was how the child would likely identify. But the parents always planned to give Ori leeway to explore. If there was a chance that Ori felt male, Turner wanted it to be clear that that was OK. She concocted a bedtime story in which doctors aren’t sure what a baby’s sex is, so the parents let the baby decide over time.

Around the age of 7, Ori came to Turner one night and said, “I feel like I was supposed to be a boy.”

“I was like, ‘Oh my God, thank God I didn’t make a huge mistake,’” Turner said of her decision not to do the surgery.

For several years, Ori wore boy’s clothing and wanted to be called Alex. Then, around fifth grade, Ori started to dress and behave in ways stereotypical of boys and girls — “a cute hair clip with a really masculine outfit,” Turner recalled.

In 2017, the Turners took Ori to a gathering of people who are intersex in Phoenix. There, Ori met some attendees who identified as transgender or nonbinary (neither male nor female). Ori decided to stop using the name Alex and asked to be called by gender-neutral they/them pronouns.

Ori, now 11, loves playing video games like Minecraft and is enamored with the movie franchise “How to Train Your Dragon.” Ori has not been bullied and said that being intersex is “really fun and awesome.”

Ori Turner, left, plays with their sisters at home.

The middle schooler wants to be a lawyer and an actor someday — as well as an activist “so I can help intersex kids and adults.” In March, Ori gave a TEDx Talk about growing up intersex. Turner helped with the presentation, but the gregarious preteen did most of the talking.

“I wish that [people] knew that intersex people are just like them,” Ori said. “They’re human.”


In rare cases, intersex babies need emergency surgery when they are born — for example, if they are unable to urinate properly.

But in the vast majority of cases, the operations are done to prevent a child from suffering presumed psychological distress later in life, experts said. Surgeons prefer to do these operations when children are between 6 and 18 months old — when healing is believed to be optimal and when children are too young to remember, experts said.

"It’s a violation of their human rights to choose what they want their bodies to be like."

In these cases, based on assumptions about a child’s future desires, “medically necessary” is hard to define, Chan said.

“Ultimately, my concern is that we find that things like doing some of the surgeries in infancy might be really helpful and beneficial for some individuals, and really harmful for others, and how do you balance that out?” he asked.

Parents often say that their decision to agree to surgery was at least partly driven by fear, according to a 2017 Human Rights Watch report on surgery on intersex children. There’s a growing acceptance among young Americans for those who identify outside the male-female binary — 56 percent of Generation Z kids know someone who uses gender-neutral pronouns, one survey found — and New York City recently joined four states in allowing gender-neutral birth certificates . But amid the Trump administration’s reported push to more stringently define gender identity, parents still worry about bullying, as well as the judgment their child could face in day care centers and locker rooms.

Josh and Kristina Turner

Opponents of surgery say that it is more likely to cause distress than to prevent it. For instance, if a child who undergoes feminizing surgery later identifies as male, “that’s really a catastrophe,” said Dr. Arlene Baratz, a physician and an advocate at interACT, a group that supports intersex youth.

“To do that before children have a say is, I believe it’s a violation of their human rights to choose what they want their bodies to be like,” Baratz said.


Because of the variety of intersex conditions and the range of medical advice, some experts fear California’s legislation and other efforts to restrict surgery could have a negative effect on some intersex children.

Dr. Earl Cheng, a surgeon and urologist with H. Lurie Children’s Hospital of Chicago, called the efforts “a catch-all umbrella in which one size fits all.”

“One size does not fit all,” Cheng said. “You need to have a discussion based upon exactly what that individual has.”

Some adults who underwent the surgery as children say they’re happy with the results.

Lesley Holroyd, 61, a nurse who lives in Florida, was born with congenital adrenal hyperplasia (CAH), which means she is genetically female but was overexposed to male hormones in utero.

“I’ve had no issues,” Holroyd said of having surgery as a child, adding that the thought of not having done so was “horrifying.” She said she has always seen herself as female and does not identify as intersex.

“Parents know their children certainly better than the government does."

A 2018 study found that 79 percent of adult CAH women who received surgery as children were satisfied with surgical outcomes.

The CARES Foundation, an organization that supports families with children with CAH, lobbied to make them exempt from the California resolution, saying surgery should be up to their parents.

“Parents know their children certainly better than the government does,” said Dina Matos, the group’s executive director.


While adults debate what’s best for kids like Ori Turner, the sixth-grader has already figured it out. Asked about surgery, Ori replied that it was unnecessary because “I’m perfect.”

Ori, who goes to school part time and is home-schooled the rest, is writing a children’s book about growing up as an intersex kid, tentatively titled “The Story of Ori.” The preteen wants Washington State to outlaw cosmetic surgeries on intersex infants and plans to start a petition with interACT.

Turner said parenting an intersex child has been challenging at times, especially when some relatives have criticized her choices, but she said she has learned to “stand strong” in her beliefs.

“Raising Ori is just like raising any other kid,” Turner said. “It’s raising the rest of the world that’s the problem.”


gender assignment of intersex

What Is Intersex? Here’s What the Term Means and How It Can Present

Including information on gender assignment surgery and how to provide support to the intersex community..

Jessica Migala has been a health, fitness, and nutrition writer for almost 15 years. She has contributed to more than 40 print and digital publications, including EatingWell, Real Simple, and Runner's World. Jessica had her first editing role at Prevention magazine and, later, Michigan Avenue magazine in Chicago. She currently lives in the suburbs with her husband, two young sons, and beagle. When not reporting, Jessica likes runs, bike rides, and glasses of wine (in moderation, of course). Find her @jlmigala or on LinkedIn.

gender assignment of intersex

Anju Goel, MD, MPH, is a public health consultant and physician with more than 10 years of experience in the California public health system.

gender assignment of intersex

If you've noticed the I in LGBTQIA+ , you may wonder what it means and where it came from. The I stands for intersex, a biological variance that means a person's sex doesn't fit neatly into the boxes of "male" or "female"—based on their chromosomes, genital presentation, reproductive tissue, or some combination of the three.

Learn more about what it means to be intersex and why more intersex individuals are embracing this identity.

What Does Intersex Mean?

Intersex is when a person is born with a body that doesn't fit into the definition of typical male or female genitalia—the external genitalia doesn't match the internal genitalia.

Intersex used to be known as hermaphroditism, but the latter term is outdated and no longer used. Instead, intersex conditions are referred to as disorders of sex development (DSDs). There are four categories of intersex:

Categories of Intersex

Typically females carry two X chromosomes, and males carry one X and one Y chromosome. With people who are intersex, this isn't necessarily true.

46, XX Intersex

In general, an individual who is intersex may have female chromosomes but ambiguous or male-appearing genitals. This is called 46, XX intersex which can be caused by:

46, XY Intersex

Alternatively, the individual may have male chromosomes but ambiguous or female-appearing genitals. This is called 46, XY intersex which can be caused by:

True Gonadal Intersex

A person who is intersex could have what's called true gonadal intersex, having both ovarian and testicular tissue. The cause for true gonadal intersex is unknown although there has been research done in animals that links true gonadal intersex to exposure of common agricultural pesticides .

Complex Intersex

The last category of intersex is a complex or undetermined disorder of sex development that doesn't fit neatly into any of these categories. This involves chromosome configurations other than 46, XX or 46, XY that results in sex development disorders.

Symptoms of Intersex

Being intersex is not about gender identity or sexual orientation ; it's about physical sex traits and genes. Depending on the cause, symptoms related to being intersex could include:

While intersex is typically discovered at birth, it is possible that it may not be diagnosed until puberty. Georgieann Davis, PhD , an associate professor of sociology at the University of New Mexico and author of "Contesting Intersex: The Dubious Diagnosis," was born with complete androgen insensitivity syndrome, which results in female-associated external genitalia but XY chromosomes and undescended testes.

"My parents, in my case and many others, didn't know I was intersex until I was in my teenage years and I didn't menstruate ," Davis told Health . "That's when they discovered what they didn't expect to find inside."

Gender Assignment Surgery

In the past, if a baby was born with intersex traits, healthcare providers and caregivers may have chosen a sex assignment for the child and may have elected for surgery so the child has a penis or vagina. Caregivers were often urged to make a quick decision and to have surgery as soon as possible.

"If something is framed as a medical problem or emergency, parents are likely to move forward with medical intervention because that's the option they're presented," said Davis. "Parents may later express decisional regret because they didn't have the information presented to them, that [intersex] is a natural variation of one's body that does not have to dictate one's gender identity."

Effects of Gender Assignment Surgery at a Young Age

While healthcare providers and caregivers still often choose gender assignment surgery for children who are intersex, this issue is not without contention.

Since intersex children are unable to make the decision for themselves, their caregivers choose to make that decision for them. This may result in decreased sexual function and increased substance use disorders and suicide .

More and more, caregivers forgo surgery and let the child decide at a mature age if surgery or treatment is desired. The ISNA advocates this shift—the organization recommends caregivers wait on genital surgery until a child is mature enough to make an informed decision for themself.

Before making a surgical decision, the ISNA also recommends that the child should be fully informed and introduced to people who have and have not had the surgery.

How To Provide Support

If you want to provide support for someone who is intersex, the best thing is to advocate for people to have the ability to make their own choices about their bodies, rather than a caregiver or someone else.

Social Support

Davis suggested that caregivers of intersex children reach out to other caregivers of intersex kids. Then, they can rely on other caregivers' experience and support so their children can make informed decisions about their bodies .

"I haven't met an intersex person or activist who's been against surgery," said Davis. "We're against having these surgeries done on those who don't have a say in what's done to their bodies."

Psychosocial Support

Davis also emphasized the roles of psychosocial support in the form of psychiatric counseling as well as support groups to help individuals who are intersex navigate any challenges. According to a study, 53.6% of the participants who were intersex self-reported that their mental health was fair or poor. On top of that, many of the participants noted that they were experiencing:

"We, as advocates, would like to see the psychosocial part of care be the predominant thing," said Davis. "While surgeons and endocrinologists are key, psychological counseling is of utmost importance in handling our unique identities and traits in day-to-day life. There's no proof that growing up with a body that looks different is inherently harmful."

A Quick Review

Intersex is a complex condition rooted in genetics. If a person chooses to pursue treatment for the condition, it should be on their own terms. Finally, being an ally to intersex individuals means ensuring that those individuals feel they have a sense of agency and autonomy.

Taylyn Washington-Harmon is the associate editor at Health.com. A former social media guru, she's worked for a number of lifestyle and beauty brands and has previously written for SELF and STAT. She loves skincare, anime, and her pitbull Momo.

gender assignment of intersex

MedlinePlus Medical Encyclopedia. Intersex .

American Academy of Family Physicians. Genital surgeries in intersex children .

Intersex Society of North America (ISNA). What does ISNA recommend for children with intersex? .

Rosenwohl-Mack A, Tamar-Mattis S, Baratz AB, et al. A national study on the physical and mental health of intersex adults in the U.S.   PLOS ONE . 2020;15(10):e0240088. doi:10.1371/journal.pone.0240088

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Current views on evaluation, management, and gender assignment of the intersex infant

Nature Clinical Practice Urology volume  1 ,  pages 38–43 ( 2004 ) Cite this article

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In recent years, traditional views regarding the management of infants with intersex conditions have been challenged. Some of these patients have gender dysphoria and gender conversion, although most adults with intersex consider themselves to be either male or female. Hormonal and genetic factors may have a more important role in gender identity and sexual satisfaction than previously recognized, whereas the importance of phallus size to male gender identity and sexual satisfaction may have been overestimated. The impact of androgen imprinting on the developing brain is uncertain, but it is likely to be significant. The issue of genital surgery in infancy is controversial, although many adult patients concur that infancy is the best time for such procedures. Several reports indicate that the functional outcomes of genital surgery are poor, although more recently developed surgical techniques may achieve better results. Good communication between physicians, patients, and families regarding intersex conditions is paramount. We review current understanding of the evaluation and management of intersex conditions.

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gender assignment of intersex

There’s a lot more to being male, female, or any gender than the sex assigned at birth. Your biological or assigned sex does not always tell your complete story.

What are the differences between sex, gender, and gender identity?

It’s common for people to confuse sex, gender, and gender identity.  But they’re actually all different things.

Sex is a label — male or female — that you’re assigned by a doctor at birth based on the genitals you’re born with and the chromosomes you have. It goes on your birth certificate.

Gender is much more complex: It’s a social and legal status, and set of expectations from society, about behaviors, characteristics, and thoughts. Each culture has standards about the way that people should behave based on their gender. This is also generally male or female. But instead of being about body parts, it’s more about how you’re expected to act, because of your sex.

Gender identity is how you feel inside and how you express your gender through clothing, behavior, and personal appearance. It’s a feeling that begins very early in life.

What’s assigned sex (aka “biological sex”)?

Assigned sex is a label that you’re given at birth based on medical factors, including your hormones, chromosomes, and genitals. Most people are assigned male or female, and this is what’s put on their birth certificates.

When someone’s sexual and reproductive anatomy doesn’t seem to fit the typical definitions of female or male, they may be described as intersex .

Some people call the sex we’re assigned at birth “biological sex.” But this term doesn’t fully capture the complex biological, anatomical, and chromosomal variations that can occur. Having only two options (biological male or biological female) might not describe what’s going on inside a person’s body.

Instead of saying “biological sex,” some people use the phrase “assigned male at birth” or “assigned female at birth.” This acknowledges that someone (often a doctor) is making a decision for someone else. The assignment of a biological sex may or may not align with what’s going on with a person’s body, how they feel, or how they identify.  

The factors that determine our assigned sex begin as early as fertilization .

Each sperm has either an X or a Y chromosome in it. All eggs have an X chromosome.

When sperm fertilizes an egg, its X or Y chromosome combines with the X chromosome of the egg.

A person with XX chromosomes usually has female sex and reproductive organs, and is therefore usually assigned biologically female.

A person with XY chromosomes usually has male sex and reproductive organs, and is therefore usually assigned biologically male.

Other arrangements of chromosomes, hormones, and body parts can happen, which results in someone being intersex .

What’s gender?

Gender is much bigger and more complicated than assigned sex. Gender includes gender roles , which are expectations society and people have about behaviors, thoughts, and characteristics that go along with a person’s assigned sex.

For example, ideas about how men and women are expected to behave, dress, and communicate all contribute to gender. Gender is also a social and legal status as girls and boys, men, and women.

It’s easy to confuse sex and gender. Just remember that biological or assigned sex is about biology, anatomy, and chromosomes. Gender is society’s set of expectations, standards, and characteristics about how men and women are supposed to act.

What’s gender identity?

Your gender identity is how you feel inside and how you express those feelings.  Clothing, appearance, and behaviors can all be ways to express your gender identity.

Most people feel that they’re either male or female.  Some people feel like a masculine female, or a feminine male. Some people feel neither male nor female. These people may choose labels such as “genderqueer,” “gender variant,” or “gender fluid.”  Your feelings about your gender identity begin as early as age 2 or 3.

Some people’s assigned sex and gender identity are pretty much the same, or in line with each other. These people are called cisgender. Other people feel that their assigned sex is of the other gender from their gender identity (i.e., assigned sex is female, but gender identity is male). These people are called transgender or trans. Not all transgender people share the same exact identity.

Are you a teenager who wants support?

Q Chat Space hosts live chats where LGBTQ+ teens can give and receive support.

Book an Appointment

Please enter your age and the first day of your last period for more accurate abortion options. Your information is private and anonymous.

Or call 1-800-230-7526

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Dr Graham – A Gender Therapist Online, who specializes in Gender Dysphoria and its related issues, who has practiced Worldwide as a Transgender Health Care Specialist for the past 20 years.

gender assignment of intersex

For some individuals, the determination of biological sex can be difficult. Intersex refers to genetically determined differences in the reproductive system.  This can include differences in internal reproductive organs, external genitalia, or Karyotype. Mild intersex conditions include, in males, a condition in which the urethra opens on the underside of the penis or, in females, an enlarged clitoris. Female intersexual (Karyotype 46XX) (also called female pseudohermaphrodites) have a normal ovarian tissue, and have either male or ambiguous genitalia. This is usually a result of a change in the foetal adrenal glands, leading to the production of abnormally high levels of androgens. The androgens produce some masculine features in female infants: ovaries and uterus form, but the external genitalia appear male-like. This accounts for about two-thirds of intersex states. 

Male inter-sexuality (Karyotype 46XY) (also called male pseudohermaphrodites) have normal testes with female or ambiguous genitalia. They most often result from several different genetic alterations in pathways of testosterone synthesis and metabolism. For example, males who have a mutation in the gene that converts testosterone to dihydroxy testosterone have normal testes but have a very small penis and a vaginal pouch. In gonadal dysgenesis the testes fail to secrete androgens or Müllerian-inhibiting hormone, leading to formation of female genitalia. With Estrogen treatment, however, these individuals will grow into females. A condition called micro-penis results from a lack of androgens later in foetal life; testosterone treatment can stimulate musicalizing puberty in these individuals. 

Androgen insensitivity syndrome (AIS) occurs when a male produces cells that cannot respond to androgen. The defect is in a gene on the X chromosome that produces the androgen receptor. Individuals may have complete or partial androgen insensitivity. In complete AIS the testes develop in the embryo and produce testosterone and the hormone that inhibits development of female internal reproductive organs (Fig. 4). However, because the cells do not respond to testosterone, female genitals develop, which may be incomplete. The new born appears to be a female and develops external female characteristics at puberty. Lacking internal female reproductive organs, though, the individual with AIS does not menstruate and is infertile. In incomplete AIS, individuals may appear male or female, but there may be abnormalities of the external genitalia. Maria Patino, a Spanish runner with complete AIS, was not allowed to compete in the 1985 World University Games in Kobe, Japan because she failed the gender test. (See the Sex and Gender video.) Because of such difficulties in determining sex, the International Olympic Committee abolished gender testing in 1999.

Ethics of Intersex Treatment

Common medical treatments of Intersex babies include:

1. Assignment of gender based on a variety of clinical tests 2. Surgery to remove internal gonads that might become cancerous 3. Reconstruction of external genitalia appropriate for the assigned sex 4. If necessary, treatment with appropriate hormones

Unless a penis is present, most Intersex babies are assigned female because it is not possible to construct a fully functional penis. The gender assignment and the surgery are usually done immediately after birth, with possible additional surgery after puberty.  

Today, some physicians such as Eric Vilain (featured in the video) recommend allowing the child to make his or her own surgical decisions later in life. However, most parents choose the surgery earlier because they are uncomfortable with the ambiguity. 

The Intersex Society of North America believes that Intersex is not an abnormality but rather “an anatomical variation from the standard male and female types 

The Society also believes that the decision regarding treatment, if any, should be made by the individual when he or she is capable of informed consent. The Society has two objections to treatment:

1) treatment assumes that Intersexuality is a disease, and 

2) surgery often damages sexual function, while still failing to produce anatomically normal genitals. They claim that physicians have traditionally failed to communicate to parents the basis for the assignment of gender, which is not always (and in the case of XY individuals without a penis, never) made based on biological sex. They also claim that some physicians have failed to inform parents of alternatives and presented elective surgery as essential for health. 

3) Physicians were once guided by the idea that infants are gender neutral at birth, and that normal gender development would follow from the environment of the child based on the sex assigned to the child

4) They believed that gender came from “nurture” rather than “nature.” In recent years individuals, especially Intersexual, have protested that the environment does not control gender and, given that the treatments are irreversible, they should be delayed until the child determines his or her true gender. Others worry, however, that children with ambiguous genitals will be ridiculed, causing permanent psychological damage that could be avoided. 

REF: http://www.learner.org

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Nih style guide, sex, gender, and sexuality.

AP Stylebook: Gender, sex, and sexual orientation

For a thorough list of terminology about sexual and gender minorities, please reference the Office of Equity, Diversity, and Inclusion’s LGBTI-SafeZone Terminology page .

Bisexual people have the potential to be emotionally, romantically, or sexually attracted to people of the same and different gender—not necessarily at the same time, in the same way, or to the same degree.

A cisgender person is someone whose gender identity aligns with the sex assigned to them at birth; sometimes abbreviated as cis . Use cisgender first with cis in parentheses after it if you use the abbreviation in your writing. 

Gender refers to socially constructed roles, behaviors, activities, and/or attributes that a given society associates with being a woman, man, girl, or boy, as well as relationships with each other. As a social construct, gender varies from society to society and can change over time.

Gender affirmation, gender confirmation, transition, transitioning

Use the terms above rather than the terms transgendering, sex change, the surgery, or pre-operative/post-operative. Gender affirmation and transition define the interpersonal, interactive process where a person receives social recognition and support for their gender identity and expression. This process can but does not necessarily involve medical intervention, which can include hormone therapy and one or more surgeries to affirm one’s gender. Pre-/post-operative may still be used in medical literature but should not be applied to a specific person without their consent.

Gender expression

Gender expression is how one chooses to convey one’s gender identity through behavior, clothing, and other external characteristics.

Gender identity

An individual’s sense of being a man, woman, boy, girl, genderqueer, nonbinary, etc. This identity is not necessarily visible to others.

Gender non-conforming

A person whose gender expression is not consistent with the societal or cultural norms expected of that gender.

Intersex and differences in sex development

Intersex is a general term used to refer to individuals born with, or who develop naturally in puberty, biological sex characteristics that are not typically male or female. Never use the term hermaphrodite . Differences in sex development (DSD) is an inclusive umbrella term; some people with DSD identify as intersex.

LGBTQIA+ stands for lesbian, gay, bisexual, transgender, queer, intersex, and asexual. The plus sign includes other members of the community, such as genderfluid, nonbinary, or two-spirit, among others.

Use LGBTQIA+ when writing about the community outside of research contexts, e.g., community engagement or Pride. Use sexual and gender minority (SGM) populations when referring to health research and policy.

To misgender is to refer to someone, especially a transgender or gender diverse person, using a word or address that does not correctly reflect their gender identity.

A nonbinary person identifies outside of a gender binary by seeing themselves as neither a man nor or woman. Nonbinary people are part of the trans community.

Use pronouns that correspond to a person’s gender identity. Because gender identity is an internal characteristic that should not be assumed, asking for a person’s pronouns is the best practice. In addition to the binary English pronouns she/her and he/his , some people may use nonbinary pronouns, including the pronouns they/them used as singular terms, among others. When using the singular they , still conjugate the verb as a plural, as in, “they are gender nonbinary.”

When writing about a hypothetical person, like an anonymous participant in a study enrolling people of all genders, use the singular they rather than he or she .

Please review Gender Pronouns and Their Use in Workplace Communications for a more in-depth discussion.

The term queer is more fluid and inclusive than traditional categories for sexual orientation and gender identity. Once considered a pejorative term, queer has been reclaimed by some LGBTQIA+ people to describe themselves; however, it is not a universally accepted term even within the LGBTQIA+ community. People who identify as queer may think of their sexual orientation and/or gender identity as characterized by nonbinary constructs of sexual orientation, gender, and/or sex. Queer should only be used to describe members of the community who themselves identify with it.

Sex, sexual

A biological category based on reproductive, anatomical, and genetic characteristics, generally defined as male, female, and intersex.

Sex is used when describing anatomical, chromosomal, hormonal, cellular, and basic biological phenomena. E.g., sex development, sex hormones, sex characteristics.

Sexual is used when referring to sexual identity, attraction, and activity, as well as related physiological, psychological, or behavioral processes. E.g., sexual orientation, sexual minority, sexual health, sexual behavior.

Sexual and gender minority

Sexual and gender minority (SGM) populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex. Individuals with same-sex or -gender attractions or behaviors and those with a difference in sex development are also included. These populations also encompass those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by non-binary constructs of sexual orientation, gender, and/or sex.

Use sexual and gender minority (SGM) populations as a broad, umbrella term when referring to LGBTQIA+ communities as a singular population in the context of health research, related activities, and policy. Use LGBTQIA+ when identity is important (e.g., community engagement, Pride messaging). When writing about a specific research project or study, always use the population terms identified and defined by the investigators for that study. For example, a study could be examining outcomes among sexual minority women, while another may look at LGB people. In these instances, using SGM populations or LGBTQIA+ would not be appropriate. For more information, see the Sexual and Gender Research Minority Office’s website .

Sexual orientation

Use sexual orientation rather than sexual preference . Preference suggests that non-heterosexuality is a choice, a concept often used to discriminate against the LGBTQIA+ community. Preference also suggests a selection from two or more choices, excluding bisexual people and pansexual people, among others.

Transgender, trans

AP Stylebook: Transgender Coverage Topical Guide A transgender person is someone who identifies with a gender other than the one that was assigned to them at birth. Use the term transgender or trans and not transgendered . Transgendered is a dated term that suggests a point in time when a person “became” transgender, which diverges from the lived experiences of most transgender people. Trans is an adjective that helps describe someone's gender identity, and it should be treated like other adjectives (e.g., trans man, trans woman ). Merging the adjective and the noun risks suggesting that a trans man or woman is more (or less) than just a man or just a woman, which goes against how many trans people identify themselves.

A person who identifies as having both a masculine and a feminine spirit and is used by some Indigenous people to describe their sexual, gender, and/or spiritual identity. Traditionally, American Indian two-spirit people were male, female, and sometimes individuals with intersex traits who combined activities of both men and women, with traits unique to their status as two-spirit people; they occupied a distinct, alternative gender status.

Various spellings of Two Spirit exist, including uppercase, lowercase, and hyphenated or with a number (e.g. 2Spirit, Two Spirit, two-spirit ). 2S is the most common abbreviation. Consensus on spelling isn’t set, but Two Spirit is most frequently used.

This page last reviewed on December 8, 2022

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Deciding on gender in children with intersex conditions: considerations and controversies


Biologic factors such as genetic and hormonal influences contribute to gender identity, gender role behavior, and sexual orientation in humans, but this relationship is considerably modified by psychologic, social, and cultural factors. The recognition of biologically determined conditions leading to incongruity of genetically determined sex, somatic phenotype, and gender identity has led to growing interest in gender role development and gender identity in individuals with intersex conditions. Sex assignment of children with ambiguous genitalia remains a difficult decision for the families involved and subject to controversial discussion among professionals and self-help groups. Although systematic empirical data on outcomes of functioning and health-related quality of life are sparse, anecdotal evidence from case series and individual patients about their experiences in healthcare suggests traumatic experiences in some. This article reviews the earlier 'optimal gender policy' as well as the more recent 'full consent policy' and reviews published data on both surgical and psychosocial outcomes. The professional debate on deciding on sex assignment in children with intersex conditions is embedded in a much wider public discourse on gender as a social construction. Given that the empirical basis of our knowledge of the causes, treatment options, long-term outcomes, and patient preferences is insufficient, we suggest preliminary recommendations based on clinical experience, study of the literature, and interviews with affected individuals.

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Surgeries on Intersex Infants are Bad Medicine

By: Cathren Cohen

Sex, gender, and medical interventions for young people have been widely discussed in state legislatures this year, with a record number of states introducing bills which would limit or prohibit gender-affirming care for transgender youth. Gender-affirming care is supported and recognized as good health care by professional medical organizations and transgender advocates alike. While state lawmakers have rushed to keep transgender youth from receiving care they need, their bills permit non-consensual and harmful surgeries on intersex infants to continue. What lawmakers should be focused on is banning these unnecessary and dangerous medical interventions.

What does it mean to be intersex?

“ Intersex ” is an umbrella term that refers to people with one or more of a range of variations in sex characteristics that fall outside the traditional conceptions of male or female bodies. Some of these differences are apparent at birth while others become noticeable later in life, such as during puberty. While less people tend to have awareness of intersex people and the issues they face, being intersex is actually fairly common; approximately 1-2 percent of the population is intersex, comparable to the percentage of people who are redheads!

There are many possible differences in genitalia, hormones, internal anatomy, or chromosomes which do not fit neatly into the binary sex categories into which people are typically assigned at birth. Intersex conditions include hormone conditions , such as Androgen Insensitivty Syndrome or Congenital Adrenal Hyperplasia, in which the body does not process hormones in the typical way, resulting in differences in the physical development of internal and external sex organs. There are over 40 medical terms of the different ways sex anatomy might develop; importantly though, advocates stress that all children should have bodily autonomy regardless of classification into a specific category.

What are intersex surgeries and why are they harmful?

Intersex surgeries are non-lifesaving procedures that change natural variations in genital appearance or reproductive anatomy. Intersex surgeries include reducing or repositioning a clitoris (which can result in the loss of sexual sensation), creating or altering a vagina, moving a urethra that already works, and removing organs that would make sex hormones (such as gonadectomy, which can result in sterilization).

Rather than being based on medical necessity, the history of intersex surgeries is rooted in heteronormative and patriarchical perspectives about sex, gender, and marriage. Beginning in the mid-twentieth century, doctors began performing surgeries on intersex infants and children to make their genitals appear more “normal.” In addition to having the goal of reinforcing a binary view of sex and gender, the prevailing view among medical practioners was that young people would feel shame over their intersex characteristics and that without surgery they would not be able to have a normal marriage or sex life.

Because of this shame-based view, these  young people, and even their parents, may not be told that they are intersex. It is not uncommon for intersex children not to know they are intersex or to be lied to and told that the surgeries were necessary to prevent cancer, rather than to “normalize” the appearance of their genitalia.

While some intersex conditions can present issues making or regulating hormones or can carry other health risks , for the vast majority of intersex infants, surgical intervention is not medically necessary . Rather, intersex surgeries — most of which are done when children are under 2 years old — can create life-long harms. These surgeries can result in scarring, chronic pain, chronic incontinence, loss of sexual sensation, sterilization, inaccurate gender assignment, and trauma.

Intersex surgeries violate medical ethics and standards of care.

The practice of performing unnecessary surgeries on infants and children is in direct conflict with medical ethics and standards of care. Ethical standards require health providers to allow patients to make decisions about their own health and treatment . But when these life-changing surgeries are performed on children whose average age is 2, there is no way for the intersex person to make their own decisions about a procedure that will affect their fertility, sexual function, and emotional well-being for the rest of their lives. Similarly, the practice of informed consent , wherein providers disclose relevant and medically accurate information about treatment choices and alternatives, is crucial to this decision-making process. But informed consent cannot happen when children and parents who are not told the true reasons for different procedures and, as a result, are denied the opportunity to decline an unwanted surgery.

What can we do to end nonconsensual intersex surgeries?

Intersex advocates, such as   interACT: Advocates for Intersex Youth , the TGI Justice Project , and the Intersex Justice Project , organize to end intersex surgery and hold doctors and hospitals accountable for violating medical ethics and patient autonomy. One avenue to end surgeries is legislative action: five states have introduced bills to prohibit intersex surgery, but none have passed yet. For example, California Senator Scott Weiner introduced California Senate Bill 225 (the “Bodily Autonomy, Dignity and Choice Act”) which would have prohibited physicians and surgeons from performing certain sex organ modification procedures on intersex children under age 12. While that bill will now not be considered until next year, it has raised awareness of the need to address this harmful practice.

Further, prohibiting insurance coverage of surgeries on intersex youth should be considered to limit this practice. While we know that many transgender individuals face barriers getting insurance programs to cover their medically-necessary and ethically sound gender-affirming surgical care, surgeries without the specific consent of the intersex youth are often covered by insurance. Insurance coverage is often available because these surgeries are deemed “reconstructive” or “corrective,” but this determination is left to physicians, not intersex people or their families, despite the fact that intersex surgeries are not needed to “correct” a medical issue.

Intersex activists have lobbied hospitals directly to stop intersex surgeries from being performed in their facilities. In a first-of-its-kind victory for the movement, in July 2020 the Ann & Robert H. Lurie Children’s Hospital of Chicago announced it would no longer perform surgeries on intersex infants who are unable to consent and apologized to the intersex people who had been harmed by its sex development clinic. Similarly, in October 2020, Boston Children’s Hospital announced they would stop performing two types of intersex surgery (clitoroplasty or vaginoplasty) on children too young to consent. Activists continue to advocate for other hospitals to stop intersex surgeries, and in 2018 released the nation’s first intersex-affirming hospital policy guide , which calls for the creation of clear policy that encourages the delay of any surgical procedures until an intersex individual is old enough to make an informed decision.

Intersex people, like all patients, have the right to be informed of their treatment options and associated risks, to determine their own course of treatment, and to be protected from harmful and unnecessary procedures. Performing unnecessary surgeries on intersex infants fails to live up to medical ethics and violates the bodily autonomy of intersex people. Lawmakers and advocates should work to enact protections to ensure that performing such surgeries on young children are banned.

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Intersex Human Rights Australia

What is intersex.

By Admin . First posted 2 August 2013 . Content last reviewed 24 February 2021

a four piece jigsaw, falling into place

Working definition

As a simple working definition of intersex, Intersex Human Rights Australia uses the following statement:

Intersex people have innate sex characteristics that don’t fit medical and social norms for female or male bodies, and that create risks or experiences of stigma, discrimination and harm.

This definition is based on definitions shared by the UN Office of the High Commissioner for Human Rights. The statement relies on a definition of sex characteristics. The following definition of sex characteristics is based on the Yogyakarta Principles plus 10 :

Sex characteristics are physical features relating to sex, including chromosomes, genitals, gonads, hormones, and other reproductive anatomy, and secondary features that emerge from puberty.

It is worth taking time to recognise that this definition does not specify particular biological characteristics, birth assignment, legal status, gender, gender identity or sexual orientation. Intersex people do not share any identity, we are a very diverse population. Intersex people old enough to freely express an identity can be heterosexual or not, and cisgender (identify with sex assigned at birth) or not. If you’re looking for a word meaning non-intersex, that word is endosex.

Intersex traits include a wide range of different underlying variations. These can be determined prenatally, at birth, during puberty and at other times, such as when trying to conceive a child. Each trait has its own characteristics and differing degrees of expression. The term intersex is best described as an umbrella.

What terms individuals use ourselves

Intersex people are a diverse population with many different intersex traits and other characteristics. Individual people with intersex variations use a variety of different terms, including being intersex, having an intersex variation or condition, having an innate variation of sex characteristics, or naming specific traits. The intersex community comes together to tackle stigma, discrimination and harm, and to celebrate our diverse bodies.

An Australian sociological survey of 272 people born with atypical sex characteristics in 2015 received responses from people with 5-alpha-reductase deficiency, complete and partial androgen insensitivity syndrome (AIS), bladder exstrophy, clitoromegaly, congenital adrenal hyperplasia (CAH), cryptorchidism, De la Chapelle (XX Male) syndrome, epispadias, Fraser syndrome, gonadal dysgenesis, hyperandrogenism, hypospadias, Kallmann syndrome, Klinefelter syndrome/XXY, leydig cell hypoplasia, Mayer- Rokitansky-Küster-Hauser syndrome (MRKH, mullerian agenesis, vaginal agenesis), micropenis, mosaicism involving sex chromosomes, mullerian (duct) aplasia, ovo-testes, progestin induced virilisation, Swyer syndrome, Turner’s syndrome/X0 (TS), Triple-X syndrome (XXX).

The Australian sociological study deliberately used a generic study title to facilitate questions about the language participants used and where. It identified that people code switch, that is, participants used different language with different types of people. Individuals make decisions about the language they use based on what they know about themselves, the words they are taught by parents or clinicians or others, and experience of stigma and misconceptions. It is important to respect individuals’ choices, while IHRA also takes a position opposing ‘disorders of sex development’, and retconned terms using the same ‘DSD’ acronym, as it inherently disorders intersex traits.

Darlington retreat

Members of Australian and Aotearoa/NZ intersex organisations, and independent advocates, in Darlington, Sydney, in March 2017. Read our joint Darlington Statement . Photo courtesy of Phoebe Hart.

Earlier definitions

We have discontinued use of earlier definitions of intersex, below.

Our immediate prior recommended definition referred to people “born with” particular sex characteristics. While accurate, reference to birth was often misconstrued as suggesting that intersex people are necessarily identified at birth, and misconstrued as making intersex traits necessarily something related to birth assignment. The new definition is aimed at tackling this narrowed idea of who we are. The reality is that we are a diverse population who discover that we have intersex variations at many different life stages.

An earlier definition was based on the Sex Discrimination Act (Cth). It was discontinued for two reasons. Firstly, because it is primarily based on a model of deficits, what we don’t have, or what we lack, Secondly because, even though it refers to physical features, it has frequently and incorrectly been imputed to mean something about identity or sex classifications:

Intersex people are born with physical, hormonal or genetic features that are neither wholly female nor wholly male; or a combination of female and male; or neither female nor male.

International definitions

Internationally, definitions have converged in recent years, and shifted towards a model based on human rights law rather than medical definitions. This definition is simply expressed in a 2019 background note on intersex by the Office of the UN High Commissioner for Human Rights:

Intersex is an umbrella term used to describe a wide range of innate bodily variations of sex characteristics. Intersex people are born with physical sex characteristics (such as sexual anatomy, reproductive organs, hormonal patterns and/or chromosomal patterns) that do not fit typical definitions for male or female bodies

A shorter Fact Sheet with a closely similar definition is available in a number of languages via the Free & Equal campaign.

In 2016, the Asia Pacific Forum of National Human Rights Institutions published a manual on sexual orientation, gender identity and sex characteristics, defining intersex as:

An umbrella term used to describe people born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies.

Earlier definitions include, for example, a definition by the Council of Europe, in a 2013 explanatory memorandum to Resolution 1952 on children’s right to physical integrity :

The term “intersex” refers to atypical and internal and/or external anatomical sexual characteristics, where features usually regarded as male or female may be mixed to some degree. This is a naturally occurring variation in humans and not a medical condition. It is to be distinguished from transsexuality, a phenomenon where someone has an evident sex, but feels as if he or she belongs to the other sex and is therefore ready to undergo a medical intervention altering his or her natural sex.

Australian definitions

In the 2015 report, “ Resilient Individuals: Sexual Orientation Gender Identity & Intersex Rights 2015 “, the Australian Human Rights Commission defines intersex as:

The term ‘intersex’ refers to people who are born with genetic, hormonal or physical sex characteristics that are not typically ‘male’ or ‘female’. Intersex people have a diversity of bodies and identities.

The Commonwealth Sex Discrimination Amendment (Sexual Orientation, Gender Identity and Intersex Status) Act 2013 added the following definition to federal anti-discrimination law:

intersex status means the status of having physical, hormonal or genetic features that are: (a) neither wholly female nor wholly male; or (b) a combination of female and male; or (c) neither female nor male.

Note that this definition deliberately contains no barrier preventing people perceived to be intersex from gaining protection from the law. The definition of “intersex status” is also differentiated from both “sex” and “gender identity”.

2013 Australian Commonwealth guidelines on sex and gender recognition underwent minor revision in 2015 . Previously the introduction to the guide stated:

An intersex person may have the biological attributes of both sexes or lack some of the biological attributes considered necessary to be defined as one or the other sex. Intersex is always congenital and can originate from genetic, chromosomal or hormonal variations. Environmental influences such as endocrine disruptors can also play a role in some intersex differences. People who are intersex may identify their gender as male, female or X.

Now the guide states:

12. The term intersex refers to people who are born with genetic, hormonal or physical sex characteristics that are not typically ‘male’ or ‘female’. Intersex people have a diversity of bodies and gender identities, and may identify as male or female or neither.

This is contradicted somewhat by the definition of ‘X’, a third gender classification, as “ Indeterminate/Intersex/Unspecified “. In September 2015, OII Australia, together with the National LGBTI Health Alliance, Transgender Victoria and other organisations formally requested that ‘X’ be redefined as “non-binary” in the guidelines .

The three gender options comprise the full range of options available according to the guidelines, but some intersex people have other identities not covered in the guidelines.

Medical definitions

It is important to note that an invitation-only meeting in Chicago in 2006 reported in “ Summary of Consensus Statement on Intersex Disorders and Their Management “ coined a controversial new term, “Disorders of Sex Development” aimed at replacing the term intersex in medical settings:

“disorders of sex development” (DSD) is proposed to indicate congenital conditions with atypical development of chromosomal, gonadal, or anatomic sex.

Stated due to “ [a]dvances in molecular genetic causes of abnormal sexual development and heightened awareness of the ethical and patient-advocacy issues “, this new language reasserted medical authority in the light of successful intersex activism that identified our issues as human rights, and is strongly contested. It pathologises intersex variations as inherently disordered, and according to Morgan Holmes , “ reinstitutionalises clinical power to delineate and silence those marked by the diagnosis “. Intersex Human Rights Australia opposes use of the term DSD because of these factors.

Since 2013, a range of medical and scientific papers have employed a variety of language such as “ intersex “, “ intersex traits “, “ diverse sex development “, and “ diverse sex development, also known as intersex (DSDI) “.

The World Health Organization’s Genomic resource centre gives an undated definition:

Intersex is defined as a congenital anomaly of the reproductive and sexual system.

A 2014 joint paper on “ Eliminating forced, coercive and otherwise involuntary sterilization ” by the World Heath Organization, OHCHR, UN Women, UNAIDS, UNDP, UNFPA and UNICEF states simply that “ Intersex persons …[are] born with atypical sex characteristics. ” The report makes a series of recommendations aimed at changing current clinical practices, improving health outcomes and human rights, and providing reparations.

If you want a word for “non-intersex”, that word is “endosex”, for “within” or internal to sex characteristic norms. Some people may use the term “dyadic” with the same intent.

More information

This page is not intended as an introduction to intersex.

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    Deciding on gender in children with intersex conditions: considerations and controversies Biologic factors such as genetic and hormonal influences contribute to gender identity, gender role behavior, and sexual orientation in humans, but this relationship is considerably modified by psychologic, social, and cultural factors.

  17. Surgeries on Intersex Infants are Bad Medicine

    Rather, intersex surgeries — most of which are done when children are under 2 years old — can create life-long harms. These surgeries can result in scarring, chronic pain, chronic incontinence, loss of sexual sensation, sterilization, inaccurate gender assignment, and trauma. Intersex surgeries violate medical ethics and standards of care.

  18. What is intersex?

    Now the guide states: 12. The term intersex refers to people who are born with genetic, hormonal or physical sex characteristics that are not typically 'male' or 'female'. Intersex people have a diversity of bodies and gender identities, and may identify as male or female or neither.