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Q is a composite of five voices, recorded and then altered to match a gender-neutral range of pitches, as defined by a linguist and researcher. It's scientific and definably gender-neutral, and it establishes criteria by which other assistants could follow suit.

Q checks a lot of the boxes that tech companies frequently call upon to justify their own gendered virtual assistants: warmth, helpfulness, a sense of authority. I can imagine Q reading out news headlines or a text from a relative. It even has a pleasantly ambiguous European accent.

Virtue and Copenhagen Pride have high ambitions to embed the virtual assistant in everything from personal tech to public transit.

"We aim to get the attention of leading technological companies that work with AI to ensure they are aware that a gender binary normativity excludes many people and to inspire them by showing how easy it would actually be to recognize that more than two genders exist when developing artificial intelligence devices. This is about giving people choices and options," Thomas Rasmussen, head of communication for Copenhagen Pride said in a statement announcing Q.

The only hitch: Q is just a voice at this point. There's no AI framework underpinning the assistant, which means Q can't actually understand and address your requests yet.

Meanwhile Siri, Alexa, Cortana and Google Assistant can't seem to break out of the female-first image they were made in. Q could help with that.
-CNBC's Ryan Browne contributed to this report. WATCH: Social media detox - why quitting Instagram and Facebook made me happier

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Imagine if Alexa had no gender - researchers have created a voice that is neither male nor female

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Q is a composite of five voices, recorded and then altered to match a gender-neutral range of pitches, as defined by a linguist and researcher. It's scientific and definably gender-neutral, and it establishes criteria by which other assistants could follow suit.

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Doctors in the UK routinely lied to patients with disorders of sex development known as intersex conditions, the BBC has found.

A leading paediatric consultant told BBC Radio 4 that withholding the truth of patients' diagnoses had been "widespread".

Jeanette, now 71, was operated on at the age of 16 to remove her hidden testes.

She discovered the truth only when she was 50.

Jeanette was born with complete androgen insensitivity (CAIS), a genetic disorder occurring in between one in 20,000 and one in 60,000 births.

A child born with CAIS is genetically male but their body does not respond to the hormone testosterone properly, so the external appearance of their genitals will look entirely female.

Jeanette was 12 when doctors told her mother that Jeanette would not develop like other girls or be able to have a baby.

Jeanette says: "I couldn't understand at that point why she [my mum] was crying and what was wrong with me.

"Then, at 14, I started realising that things were not right with me, as I never had periods or anything."

Two years later, aged 16, Jeanette was taken to hospital and operated on, still unaware of her diagnosis.

At that time, she was told nothing - just that she needed major surgery.

"I've got an 8in [20cm] scar right across my stomach. I was feeling perfectly healthy and I can remember sitting up in up in bed, thinking, 'What the hell am I doing here?'"

Surgeons had removed internal testes from Jeanette's body, but Jeanette didn't even know she had them and doctors didn't tell her why they had operated.

Life became very difficult for Jeanette.

At 28, she got married but found sex with her husband too painful. "I was in so much pain afterwards I couldn't walk.

"So my mother came with me to hospital and they told me, 'Go home, things will get better.'"

She left her partner two years later, saying she was too "frightened" to have another physical relationship.

She did not find out the truth about her medical history until she was 50, when saw the words "testicular feminisation", another term for CAIS, on the front her medical file by chance at an outpatient appointment.

She talked with her GP, who then gave her her medical records to read.

"I read my notes and that's when it said I had the womb the size of a matchstick and two fully grown testes, and I cried my eyes out."

Intersex

There are more than 40 congenital variations of disorders of sex development

Intersex is an umbrella term used to describe people born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit into the typical notions of female or male bodies

Some traits are visible at birth, others not until puberty and some variations in chromosomes may not be physically apparent at all

Worldwide, up to 1.7% of people have intersex traits, according to the Office of the United Nations High Commissioner of Human rights

Ieuan Hughes, emeritus professor of paediatrics at the University of Cambridge and an expert in hormone disorders, says cover-ups used to be routine in cases such as this.

"In those days the consensus in the medical profession was that the truth would not be disclosed to the patient... and the general advice was for parents not to disclose the true diagnoses to the children.

"The explanation for why the person could not have periods, could not have children - a story was spun that the ovaries had not developed properly and were at risk of developing cancer, therefore they needed to be removed."

He says a number of women who had been told "a pack of lies" by the medical profession have since contacted the Androgen Insensitivity Syndrome Support Group (AISSG), with which he works.

"Apparently there had been a couple of examples where patients had been so upset they had taken their own lives - sadly."

A AISSG representative told the BBC the practice of routinely withholding the truth from patients didn't stop until 2012.

British Association of Paediatric Urologists president Stuart O'Toole said most patients were now managed within a team, with input from specialist surgeons and medics and psychologists.

"The parents of the child are involved at every stage.

"Irreversible surgery is rarely performed in infancy, and a gonad would be removed only if there was a credible risk of cancer."

The British Medical Association, the doctors union, declined to comment, but General Medical Council chief executive Charlie Massey said: "Medical practice has evolved dramatically over the last 50 years, with more and more emphasis on working in partnership with patients, openly and honestly.

"Our guidance makes it clear doctors should involve children and young people as much as possible in discussions about their care, even if they are not able to make decisions on their own.

"We are clear that doctors should not withhold information from patients, unless they believe that giving it would cause the patient serious harm."

Holly Greenbury, who co-founded Intersex UK, a campaign group founded to end stigma around intersex variations and to fight for equality and protection of intersex people, told BBC Radio 4 that some families were still feeling forced to make decisions over surgery in the UK, before children were of an age at which they could make an informed decision and consent themselves.

"What this highlights is that there is a break down of communication, a lack of education and, currently, the UK is not following internal human rights law and ensuring that our legislation protects the future wellbeing and the bodily autonomy of infants and young children."

Malta became the first country to outlaw non-consensual medical interventions on intersex, in 2015.

Intersex UK is one of several British organisations now lobbying for corrective surgery to be outlawed in the UK.

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Doctors in the UK routinely lied to patients with disorders of sex development known as intersex conditions, the BBC has found. A leading paediatric consultant told BBC Radio 4 that withholding the truth of patients' diagnoses had been "widespread". Jeanette, now 71, was operated on at the age of 16 to remove her hidden testes.

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Moving Beyond the Binary of Sex and Gender | Ugla Stefanía | TEDxReykjavik

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Evidence mounts for sex-selective abortion in Asia

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Evidence mounts for sex-selective abortion in Asia

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Sidney B. Westley - 1995

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Pose (FX) Trailer HD - Evan Peters, Kate Mara series

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Eurovision Winner 2014

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Winner - Conchita Wurst - Rise Like A Phoenix - Austria - Live at the 2014 Eurovision Song Contest

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In recent years, dialogues about what it means to be a woman and how these definitions interact with the persisting intersectional feminist movement have moved from ivory towers to the red carpet, the streets, and living rooms nationwide. Yet still, nonbinary and gender-nonconforming people's lived experiences are erased. Nonbinary femme folk, in particular, confront violence and marginalization - as well as joy, love, and triumph - in their own ways. They exist not in the standard pink or blue, but in the lavender expanses of life. Here, we take a deeper look into the lavender.

Eddie Jarel Jonesx, 24
Pronouns: he/she/they/sis
Cleveland, Ohio

I can't remember how young I was, but I had a love for my mom's size-6 high heels. I'd come home from school and be all by myself - so I'd dance in them, hittin' the runway, practicing walking up and down the stairs. It's funny because people nowadays say, "You know how to walk in heels better than girls!" and I'm like, "There's no shade, I've honestly been doing it a lot longer than most girls."

I started wearing makeup and clothes from the "girls" side of the store in college at Lincoln University. It was very cool to see that a lot of the Black men on campus really did not care about me presenting as femme. I was taken aback, because there's a stereotype about homophobia being more prevalent among men in the Black community. I just expected to get all of this hate - to not feel comfortable walking from my dorm to certain buildings - and I really did not have that experience. Most of the pushback came from the girls. It was just so confusing to me. I thought they didn't like me because their lashes were liftin' and mine were not.

There are some days where I wake up and I'm feeling really feminine, so I put on a full beat and wig. There are some days where I feel very feminine and I just have on a regular hat, no makeup, jeans, and a sneaker. For me, gender doesn't have anything to do with presentation. It's how you feel on the inside and where the spectrum lies that day. There's no one idea of man and woman. Once we all realize this to be true, I think the feminist and women's movements will be more open to nonbinary and gender-nonconforming people and allow us into their carefully curated spaces. At the end of the day, if you are femme in any capacity, you deserve to stand and fight with your sisters.

I don't really think there is a way to define womanhood or manhood. I erased the idea of a gender binary from my heart and mind, because it didn't do anything but reinforce patriarchy. I thought for a long time that I was a transgender woman, but, through drag and the queer scene in Brooklyn, I realized I didn't have to adhere to the stereotypical traits of what society thinks is a woman. I know where my head is, but I feel like I have this mind-over-matter mentality, so I've never felt like I had to prove my identity to anyone through appearance. For a lot of people, drag is their art and their job. For me, drag is literally a part of my identity. It's me channeling my femme side.

There are some places where people really do look at being nonbinary as a joke, but I'm not in any way ashamed of myself. I do have privilege because I'm not constantly presenting femme. To society, I present mostly as masculine. I always have to remember that society's lens is so different from a queer person's, so I have no problem correcting someone who mistakes a pronoun. Five years ago, I would punch a bitch in the face, but I got to a place where I realized you can't fight ignorance with being just as ignorant. I took a page out of Martin Luther King Jr.'s book and resisted. People expect and want you to be angry, especially if you're a person of color. They want you to do something for which they could easily antagonize you. But if you play calm and cool and walk away from a situation like that, you ultimately win the battle.

My message to young queer and nonbinary people is to not let society cookie-cut you. Don't let yourself become a byproduct of fear because society has taught you that monotony is needed. You don't need to be like everyone else to live. We can be ourselves - colorful, happy, or dark - and be at peace.

Jeffrey Marsh, 41
Pronouns: they/them
York, Pennsylvania

As nonbinary identity and gender nonconformity have become more mainstream, they're sometimes characterized as a new phenomenon. This is not only insulting to people like me - who are over 40 - but it's also insulting to imply that young people don't know what they're doing, are formless, and not to be taken seriously. This is a double-edged sword because, yes, it's on the cover of TIME, but when it's on the cover of TIME, it's going to be a 13-year-old because that's what's palatable to the general public. The media wants to put the most digestable face on nonbinary identities so that they can sell more magazines.

But when I think about the feminist movement, I think of the special brand of really virulent anti-trans feminism - the TERF (Trans-Exclusionary Radical Feminist) Movement. I tend to feel grateful that the feminism that I've encountered has been really welcoming. I've seen it refined to help the most people by including trans women and moving towards the inclusion of nonbinary or transfemme people. It's brave to go up against the deep programming we all have around the gender binary - because everyone (and cisgender feminists in particular) has been programmed to think that a vagina equals a woman, and we need to fight for women with vaginas to have rights. That last part of that statement is absolutely true, but we also need to chip away at that, having women and transfemmes who may or may not have certain parts be included in this movement.

One of the most beautiful things that transfemme and nonbinary people can offer the world is expressing ourselves without shame. We're such a beautiful group of people who can offer cis people the chance to let go and be whoever they are without shame, too.

Editor's note: The print version of this article published Aja's birthname in error. Out sincerly regrets and apologizes for the mishap.
To read more, grab your own copy of Out's March issue featuring "The Mothers and Daughters of the Movement" as the cover on Kindle, Nook and Zinio today, and on newsstands February 26. Preview more of the issue here. Get a year's subscription here.

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Nonbinary Femmes Must Be Included in the Feminist Movement

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In recent years, dialogues about what it means to be a woman and how these definitions interact with the persisting intersectional feminist movement have moved from ivory towers to the red carpet, the streets, and living rooms nationwide. Yet still, nonbinary and gender-nonconforming people's lived experiences are erased.

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Toilets, bowties, gender and me | Audrey Mason-Hyde | TEDxAdelaide

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https://nationalpost.com/entertainment/goodbye-gender-transgender-punk-icon-laura-jane-grace-burns-birth-certificate-at-north-carolina-concert

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https://nationalpost.com/entertainment/goodbye-gender-transgender-punk-icon-laura-jane-grace-burns-birth-certificate-at-north-carolina-concert

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https://nationalpost.com/entertainment/goodbye-gender-transgender-punk-icon-laura-jane-grace-burns-birth-certificate-at-north-carolina-concert

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Saying goodbye to binary gender | Pani Farvid | TEDxAuckland

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Air travelers who want to will soon be able to choose a gender option other than "male" or "female" when buying their tickets.

The new "undisclosed" or "unspecified" options are meant to make things easier for travelers and airlines as a growing number of local, state and national governments issue identification documents with alternative gender choices, according to Airlines for America, a trade group that represents many major United States carriers.

"U.S. airlines value a culture of diversity and inclusion, both in the workplace and for our passengers," the group said in a statement.

The Transportation Security Administration requires that travelers have gender markers associated with their tickets that match the identification documents they present at agency checkpoints. The new standard will make it easier for passengers who are gender nonconforming to travel with documents that more accurately represent their identities.

Transgender rights groups said the new options were good for all travelers, and especially for those who are transgender.

"Non-binary people face unnecessary, invasive and discriminatory scrutiny by airlines, airports and security services alike," said Arli Christian, the state policy director for the National Center for Transgender Equality, who uses the pronoun "they." As gender-neutral forms of identification become more widely available, they said, the change "is an important step toward ensuring safe and smooth travel for all passengers regardless of their gender."

It is up to individual airlines to choose when to make the changes, Airlines for America said. United Airlines, a member of the group, said in a statement that "in the coming weeks, customers will be able to identify themselves as M(ale), F(emale), U(undisclosed) or X(unspecified)" and that "customers who do not identify with a gender will have the option of selecting 'Mx.' as a title."

Alaska Airlines, American Airlines and Southwest Airlines are also working on introducing the new gender options, representatives for the carriers said, as is Delta Air Lines, which is not an Airlines for America member.

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U.S. Airlines to Offer New Gender Options for Non-Binary Passengers

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Air travelers who want to will soon be able to choose a gender option other than "male" or "female" when buying their tickets. The new "undisclosed" or "unspecified" options are meant to make things easier for travelers and airlines as a growing number of local, state and national governments issue identification documents with alternative gender choices, according to Airlines for America, a trade group that represents many major United States carriers.

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Image: Shutterstock / Crystal Eye Studio

The Trump administration intends to legally define sex as strictly male or female. But the science says that sex can be quite varied - and not so easily boxed into a narrow category.

This past weekend, The New York Times revealed that the U.S. Department of Health and Human Services has plans to define one's sex based exclusively upon the biological genitalia they're born with - ostensibly to make the definition of sex more consistent under civil rights laws that ban discrimination.

But herein lies a problem: A person's biological sex doesn't always fit unilaterally into male or female. And perhaps more importantly, one's gender - how one learns and chooses to socially identify across the male and female spectrum - can be much more varied.

"The idea that there are two categories that everyone can fit into is just a little bit nutty," Anne Fausto-Sterling, professor emerita of Biology and Gender Studies at Brown University, said in an interview.

"The development of sexual systems is just much more complex," she added.

Yet, such a narrow government classification - if ultimately adopted as a federal rule after being subject to a mandatory 60-day public comment as soon as this fall - would inhibit at least 1.4 million American transgender adults from being legally recognized as anything other than the sex they were designated at birth.

"The biology doesn't say there are two sexes," Andrea Ford, a medical anthropologist at the University of Chicago, said in an interview.

Biological sexes "do not always correspond in predictable ways or fall neatly into two categories," said Ford.

Beyond genitalia, there are gonads (testes and ovaries), hormones, and chromosomes that can manifest in a multitude of ways.

For example, babies with male chromosomes (XY) can can be born with testes but ambiguous genitalia, which can raise questions of gender assignment. Some women naturally produce lots of testosterone. People born with two XX chromosomes - who are typically female - may have a specific gene for male genitalia. And some people live for decades unaware that they share attributes of both sexes.

"It's convenient for people to organize things into a recognizable category, but there's definitely an infinity of ways that sex expresses itself," said Ford.

What's more, gender and sex are different, but often strongly linked, said Arthur Arnold, a research professor at UCLA's Department of Integrative Biology and Physiology, in an interview.

Gender, however, isn't restricted by the limitations of our bodies and physiology.

"What we're fundamentally talking about is gender here," said Arnold. "It's really a battle of social nomenclature. Are you going to constrain people by saying they are one sex?"

For instance, people may be uncomfortable with the gender they've been assigned, known as gender dysphoria. Accordingly, "some people may cross-dress, some may want to socially transition," and others may decide to medically transition with hormone therapies or gender affirmation surgery notes the American Psychiatric Association.

There might be something in our bodies or genes that predisposes us towards becoming a certain gender. But as of now, there's not a conclusive sexual or biological explanation for what propels us to choose a gender or place along the gender spectrum.

"It's a paradox that's unresolved," said Arnold.

The wide recognition of sexual and gender diversity isn't nearly new.

This makes the government's recent suggestion that there are scientifically just two sexes - which are determined at or before birth - perplexing at best and harmful to those who don't fit neatly into those categories, at worst.

"There's definitely an infinity of ways that sex expresses itself"

Research into gender in general isn't a new area of study.

"This goes back to the 1950s, and it's just gotten more and more clear it's right with time," said Fausto-Sterling, noting early and seminal work by sexual identity researcher John Money.

Centuries before the 1950s, Native Americans recognized - and accepted - the reality of other genders. In many tribal cultures, both males and females chose genders that weren't exclusively male or female.

"These highly-respected individuals experienced the gender spectrum fluidly and they were never condemned for who they were," according to the University of California at Santa Barbara.

Yet, in the 21st Century, Trump administration officials seek to put sex, and accordingly gender too, into a box of their choosing.

"It's an ideological stance that they're trying to reflect onto science - but the science doesn't say that," said Ford.

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The Trump administration says there are two sexes. The science says they're wrong.

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The Trump administration intends to legally define sex as strictly male or female. But the science says that sex can be quite varied - and not so easily boxed into a narrow category. This past weekend, The New York Times revealed that the U.S.

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Illustration by Jonny Wan

As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.

A 46-year-old pregnant woman had visited his clinic at the Royal Melbourne Hospital in Australia to hear the results of an amniocentesis test to screen her baby's chromosomes for abnormalities. The baby was fine - but follow-up tests had revealed something astonishing about the mother. Her body was built of cells from two individuals, probably from twin embryos that had merged in her own mother's womb. And there was more. One set of cells carried two X chromosomes, the complement that typically makes a person female; the other had an X and a Y. Halfway through her fifth decade and pregnant with her third child, the woman learned for the first time that a large part of her body was chromosomally male. "That's kind of science-fiction material for someone who just came in for an amniocentesis," says James.

Sex can be much more complicated than it at first seems. According to the simple scenario, the presence or absence of a Y chromosome is what counts: with it, you are male, and without it, you are female. But doctors have long known that some people straddle the boundary - their sex chromosomes say one thing, but their gonads (ovaries or testes) or sexual anatomy say another. Parents of children with these kinds of conditions - known as intersex conditions, or differences or disorders of sex development (DSDs) - often face difficult decisions about whether to bring up their child as a boy or a girl. Some researchers now say that as many as 1 person in 100 has some form of DSD.

When genetics is taken into consideration, the boundary between the sexes becomes even blurrier. Scientists have identified many of the genes involved in the main forms of DSD, and have uncovered variations in these genes that have subtle effects on a person's anatomical or physiological sex. What's more, new technologies in DNA sequencing and cell biology are revealing that almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body. Some studies even suggest that the sex of each cell drives its behaviour, through a complicated network of molecular interactions. "I think there's much greater diversity within male or female, and there is certainly an area of overlap where some people can't easily define themselves within the binary structure," says John Achermann, who studies sex development and endocrinology at University College London's Institute of Child Health.

These discoveries do not sit well in a world in which sex is still defined in binary terms. Few legal systems allow for any ambiguity in biological sex, and a person's legal rights and social status can be heavily influenced by whether their birth certificate says male or female.

"The main problem with a strong dichotomy is that there are intermediate cases that push the limits and ask us to figure out exactly where the dividing line is between males and females," says Arthur Arnold at the University of California, Los Angeles, who studies biological sex differences. "And that's often a very difficult problem, because sex can be defined a number of ways."

The start of sex

That the two sexes are physically different is obvious, but at the start of life, it is not. Five weeks into development, a human embryo has the potential to form both male and female anatomy. Next to the developing kidneys, two bulges known as the gonadal ridges emerge alongside two pairs of ducts, one of which can form the uterus and Fallopian tubes, and the other the male internal genital plumbing: the epididymes, vas deferentia and seminal vesicles. At six weeks, the gonad switches on the developmental pathway to become an ovary or a testis. If a testis develops, it secretes testosterone, which supports the development of the male ducts. It also makes other hormones that force the presumptive uterus and Fallopian tubes to shrink away. If the gonad becomes an ovary, it makes oestrogen, and the lack of testosterone causes the male plumbing to wither. The sex hormones also dictate the development of the external genitalia, and they come into play once more at puberty, triggering the development of secondary sexual characteristics such as breasts or facial hair.

Changes to any of these processes can have dramatic effects on an individual's sex. Gene mutations affecting gonad development can result in a person with XY chromosomes developing typically female characteristics, whereas alterations in hormone signalling can cause XX individuals to develop along male lines.

For many years, scientists believed that female development was the default programme, and that male development was actively switched on by the presence of a particular gene on the Y chromosome. In 1990, researchers made headlines when they uncovered the identity of this gene, which they called SRY. Just by itself, this gene can switch the gonad from ovarian to testicular development. For example, XX individuals who carry a fragment of the Y chromosome that contains SRY develop as males.

By the turn of the millennium, however, the idea of femaleness being a passive default option had been toppled by the discovery of genes that actively promote ovarian development and suppress the testicular programme - such as one called WNT4. XY individuals with extra copies of this gene can develop atypical genitals and gonads, and a rudimentary uterus and Fallopian tubes. In 2011, researchers showed that if another key ovarian gene, RSPO1, is not working normally, it causes XX people to develop an ovotestis - a gonad with areas of both ovarian and testicular development.

These discoveries have pointed to a complex process of sex determination, in which the identity of the gonad emerges from a contest between two opposing networks of gene activity. Changes in the activity or amounts of molecules (such as WNT4) in the networks can tip the balance towards or away from the sex seemingly spelled out by the chromosomes. "It has been, in a sense, a philosophical change in our way of looking at sex; that it's a balance," says Eric Vilain, a clinician and the director of the Center for Gender-Based Biology at the University of California, Los Angeles. "It's more of a systems-biology view of the world of sex."

Battle of the sexes

According to some scientists, that balance can shift long after development is over. Studies in mice suggest that the gonad teeters between being male and female throughout life, its identity requiring constant maintenance. In 2009, researchers reported deactivating an ovarian gene called Foxl2 in adult female mice; they found that the granulosa cells that support the development of eggs transformed into Sertoli cells, which support sperm development. Two years later, a separate team showed the opposite: that inactivating a gene called Dmrt1 could turn adult testicular cells into ovarian ones. "That was the big shock, the fact that it was going on post-natally," says Vincent Harley, a geneticist who studies gonad development at the MIMR-PHI Institute for Medical Research in Melbourne.

The gonad is not the only source of diversity in sex. A number of DSDs are caused by changes in the machinery that responds to hormonal signals from the gonads and other glands. Complete androgen insensitivity syndrome, or CAIS, for example, arises when a person's cells are deaf to male sex hormones, usually because the receptors that respond to the hormones are not working. People with CAIS have Y chromosomes and internal testes, but their external genitalia are female, and they develop as females at puberty.

Conditions such as these meet the medical definition of DSDs, in which an individual's anatomical sex seems to be at odds with their chromosomal or gonadal sex. But they are rare - affecting about 1 in 4,500 people. Some researchers now say that the definition should be widened to include subtle variations of anatomy such as mild hypospadias, in which a man's urethral opening is on the underside of his penis rather than at the tip. The most inclusive definitions point to the figure of 1 in 100 people having some form of DSD, says Vilain (see 'The sex spectrum').

But beyond this, there could be even more variation. Since the 1990s, researchers have identified more than 25 genes involved in DSDs, and next-generation DNA sequencing in the past few years has uncovered a wide range of variations in these genes that have mild effects on individuals, rather than causing DSDs. "Biologically, it's a spectrum," says Vilain.

A DSD called congenital adrenal hyperplasia (CAH), for example, causes the body to produce excessive amounts of male sex hormones; XX individuals with this condition are born with ambiguous genitalia (an enlarged clitoris and fused labia that resemble a scrotum). It is usually caused by a severe deficiency in an enzyme called 21-hydroxylase. But women carrying mutations that result in a milder deficiency develop a 'non-classical' form of CAH, which affects about 1 in 1,000 individuals; they may have male-like facial and body hair, irregular periods or fertility problems - or they might have no obvious symptoms at all. Another gene, NR5A1, is currently fascinating researchers because variations in it cause a wide range of effects, from underdeveloped gonads to mild hypospadias in men, and premature menopause in women.

Many people never discover their condition unless they seek help for infertility, or discover it through some other brush with medicine. Last year, for example, surgeons reported that they had been operating on a hernia in a man, when they discovered that he had a womb. The man was 70, and had fathered four children.

Cellular sex

Studies of DSDs have shown that sex is no simple dichotomy. But things become even more complex when scientists zoom in to look at individual cells. The common assumption that every cell contains the same set of genes is untrue. Some people have mosaicism: they develop from a single fertilized egg but become a patchwork of cells with different genetic make-ups. This can happen when sex chromosomes are doled out unevenly between dividing cells during early embryonic development. For example, an embryo that starts off as XY can lose a Y chromosome from a subset of its cells. If most cells end up as XY, the result is a physically typical male, but if most cells are X, the result is a female with a condition called Turner's syndrome, which tends to result in restricted height and underdeveloped ovaries. This kind of mosaicism is rare, affecting about 1 in 15,000 people.

The effects of sex-chromosome mosaicism range from the prosaic to the extraordinary. A few cases have been documented in which a mosaic XXY embryo became a mix of two cell types - some with two X chromosomes and some with two Xs and a Y - and then split early in development. This results in 'identical' twins of different sexes.

There is a second way in which a person can end up with cells of different chromosomal sexes. James's patient was a chimaera: a person who develops from a mixture of two fertilized eggs, usually owing to a merger between embryonic twins in the womb. This kind of chimaerism resulting in a DSD is extremely rare, representing about 1% of all DSD cases.

"Surgeons discovered that the man had a womb. He was 70."

Another form of chimaerism, however, is now known to be widespread. Termed microchimaerism, it happens when stem cells from a fetus cross the placenta into the mother's body, and vice versa. It was first identified in the early 1970s - but the big surprise came more than two decades later, when researchers discovered how long these crossover cells survive, even though they are foreign tissue that the body should, in theory, reject. A study in 1996 recorded women with fetal cells in their blood as many as 27 years after giving birth; another found that maternal cells remain in children up to adulthood. This type of work has further blurred the sex divide, because it means that men often carry cells from their mothers, and women who have been pregnant with a male fetus can carry a smattering of its discarded cells.

Microchimaeric cells have been found in many tissues. In 2012, for example, immunologist Lee Nelson and her team at the University of Washington in Seattle found XY cells in post-mortem samples of women's brains. The oldest woman carrying male DNA was 94 years old. Other studies have shown that these immigrant cells are not idle; they integrate into their new environment and acquire specialized functions, including (in mice at least) forming neurons in the brain. But what is not known is how a peppering of male cells in a female, or vice versa, affects the health or characteristics of a tissue - for example, whether it makes the tissue more susceptible to diseases more common in the opposite sex. "I think that's a great question," says Nelson, "and it is essentially entirely unaddressed." In terms of human behaviour, the consensus is that a few male microchimaeric cells in the brain seem unlikely to have a major effect on a woman.

Scientists are now finding that XX and XY cells behave in different ways, and that this can be independent of the action of sex hormones. "To tell you the truth, it's actually kind of surprising how big an effect of sex chromosomes we've been able to see," says Arnold. He and his colleagues have shown that the dose of X chromosomes in a mouse's body can affect its metabolism, and studies in a lab dish suggest that XX and XY cells behave differently on a molecular level, for example with different metabolic responses to stress. The next challenge, says Arnold, is to uncover the mechanisms. His team is studying the handful of X-chromosome genes now known to be more active in females than in males. "I actually think that there are more sex differences than we know of," says Arnold.

Beyond the binary

Biologists may have been building a more nuanced view of sex, but society has yet to catch up. True, more than half a century of activism from members of the lesbian, gay, bisexual and transgender community has softened social attitudes to sexual orientation and gender. Many societies are now comfortable with men and women crossing conventional societal boundaries in their choice of appearance, career and sexual partner. But when it comes to sex, there is still intense social pressure to conform to the binary model.

This pressure has meant that people born with clear DSDs often undergo surgery to 'normalize' their genitals. Such surgery is controversial because it is usually performed on babies, who are too young to consent, and risks assigning a sex at odds with the child's ultimate gender identity - their sense of their own gender. Intersex advocacy groups have therefore argued that doctors and parents should at least wait until a child is old enough to communicate their gender identity, which typically manifests around the age of three, or old enough to decide whether they want surgery at all.

This issue was brought into focus by a lawsuit filed in South Carolina in May 2013 by the adoptive parents of a child known as MC, who was born with ovotesticular DSD, a condition that produces ambiguous genitalia and gonads with both ovarian and testicular tissue. When MC was 16 months old, doctors performed surgery to assign the child as female - but MC, who is now eight years old, went on to develop a male gender identity. Because he was in state care at the time of his treatment, the lawsuit alleged not only that the surgery constituted medical malpractice, but also that the state denied him his constitutional right to bodily integrity and his right to reproduce. Last month, a court decision prevented the federal case from going to trial, but a state case is ongoing.

"This is potentially a critically important decision for children born with intersex traits," says Julie Greenberg, a specialist in legal issues relating to gender and sex at Thomas Jefferson School of Law in San Diego, California. The suit will hopefully encourage doctors in the United States to refrain from performing operations on infants with DSDs when there are questions about their medical necessity, she says. It could raise awareness about "the emotional and physical struggles intersex people are forced to endure because doctors wanted to 'help' us fit in," says Georgiann Davis, a sociologist who studies issues surrounding intersex traits and gender at the University of Nevada, Las Vegas, who was born with CAIS.

Doctors and scientists are sympathetic to these concerns, but the MC case also makes some uneasy - because they know how much is still to be learned about the biology of sex. They think that changing medical practice by legal ruling is not ideal, and would like to see more data collected on outcomes such as quality of life and sexual function to help decide the best course of action for people with DSDs - something that researchers are starting to do.

Diagnoses of DSDs once relied on hormone tests, anatomical inspections and imaging, followed by painstaking tests of one gene at a time. Now, advances in genetic techniques mean that teams can analyse multiple genes at once, aiming straight for a genetic diagnosis and making the process less stressful for families. Vilain, for example, is using whole-exome sequencing - which sequences the protein-coding regions of a person's entire genome - on XY people with DSDs. Last year, his team showed that exome sequencing could offer a probable diagnosis in 35% of the study participants whose genetic cause had been unknown.

Vilain, Harley and Achermann say that doctors are taking an increasingly circumspect attitude to genital surgery. Children with DSDs are treated by multidisciplinary teams that aim to tailor management and support to each individual and their family, but this usually involves raising a child as male or female even if no surgery is done. Scientists and advocacy groups mostly agree on this, says Vilain: "It might be difficult for children to be raised in a gender that just does not exist out there." In most countries, it is legally impossible to be anything but male or female.

Yet if biologists continue to show that sex is a spectrum, then society and state will have to grapple with the consequences, and work out where and how to draw the line. Many transgender and intersex activists dream of a world where a person's sex or gender is irrelevant. Although some governments are moving in this direction, Greenberg is pessimistic about the prospects of realizing this dream - in the United States, at least. "I think to get rid of gender markers altogether or to allow a third, indeterminate marker, is going to be difficult."

So if the law requires that a person is male or female, should that sex be assigned by anatomy, hormones, cells or chromosomes, and what should be done if they clash? "My feeling is that since there is not one biological parameter that takes over every other parameter, at the end of the day, gender identity seems to be the most reasonable parameter," says Vilain. In other words, if you want to know whether someone is male or female, it may be best just to ask.

# data[].attributes.attachment_link.description
Illustration by Jonny Wan As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.

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The Genderbread Person version 4 - ❤ It’s Pronounced Metrosexual

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For 2018 and beyond, my fourth take on this tasty little introduction to understanding gender.

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TRAILER   Genderquake Season   Monday 7th May

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Alaskans have shot down a so-called "bathroom bill" that would have prevented transgender people from using the bathroom corresponding with their gender identity.

Fifty-three percent of voters in Anchorage, Alaska voted "no" on Prop 1 - a citizen initiative that would have required transgender people to use public restrooms corresponding to the gender on their birth certificates, according to the Anchorage Daily News.

The initiative was proposed by nonprofit Christian policy group Alaska Family Action, and staunchly opposed by transgender activists in Alaska and around the country. The public battle over the measure was one of the most expensive in Alaska's history, according to Alaska Public Media.

The preliminary vote results are set to be certified on 17 April.

The measure - one of several similar "bathroom bills" proposed across the country in recent years - would have allowed employers to dictate which restroom trans customers and employees could use. Advocates, like Alaska Family Action's Jim Minnery, said the initiative was about protecting people's privacy.

Opponents, like Anchorage transgender activist Lillian Lennon, said it was a threat to transgender people's safety.

"If Proposition 1 were to pass, I would fear that I could be blocked from using the restroom that I identify with," she told NBC News. "I would be forced to go into a men's restroom where I wouldn't feel safe or protected, and I definitely don't think that anyone in that restroom would feel particularly comfortable with me there either."

Ms Lennon worked on the "No on Prop 1" campaign, which raised more than $824,000 for advertising, consulting services, phone banking, events, and other campaign activities, according to Alaska Public Media.

Donations came from local supporters and national organisations like the American Civil Liberties Union, Freedom for All Americans, and Planned Parenthood of the Great Northwest and Hawaii. The fundraising haul dwarfed that of the "Yes" campaign, which raised $128,000.

Alaska is represented exclusively by Republicans in the US Congress, and went for Donald Trump by more than 51 per cent in the 2016 election. Anchorage, however, is represented by a Democratic mayor, who voiced his opposition to Prop 1 the day it qualified for the ballot.

North Carolina passed the first "bathroom bill" in the US in 2016, causing outcry from residents and the business community. The state legislature repealed the bill in 2017.

Sixteen states considered introducing similar bills that year, according to the National Conference of State Legislatures, but none were passed.
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Alaskans shoot down transgender 'bathroom bill'

# data[].attributes.attachment_link.description
Alaskans have shot down a so-called "bathroom bill" that would have prevented transgender people from using the bathroom corresponding with their gender identity. Fifty-three percent of voters in Anchorage, Alaska voted "no" on Prop 1 - a citizen initiative that would have required transgender people to use public restrooms corresponding to the gender on their birth certificates, according to the Anchorage Daily News.

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Feature

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Dutee Chand Credit Credit Sohrab Hura/Magnum, for The New York Times

One day in June 2014, Dutee Chand was cooling down after a set of 200-meter sprints when she received a call from the director of the Athletics Federation of India, asking her to meet him in Delhi. Chand, then 18 and one of India's fastest runners, was preparing for the coming Commonwealth Games in Glasgow, her first big international event as an adult. Earlier that month, Chand won gold in both the 200-meter sprint and the 4-by-400-meter relay at the Asian Junior Athletics Championships in Taipei, Taiwan, so her hopes for Scotland were high.

Chand was raised in Gopalpur, a rural village in eastern India with only intermittent electricity. The family home was a small mud hut, with no running water or toilet. Her parents, weavers who earned less than $8 a week laboring on a government-issued loom, were illiterate. They had not imagined a different life for their seven children, but Chand had other ideas. Now, as she took the five-hour bus ride to Delhi from a training center in Punjab, she thought about her impending move to Bangalore for a new training program. She wondered if she would make friends, and how she'd manage there without her beloved coach, who had long been by her side, strategizing about how best to run each race and joking to help her relax whenever she was nervous. She thought little of the meeting in Delhi, because she assumed it was for a doping test.

But when Chand arrived in Delhi, she says, she was sent to a clinic to meet a doctor from the Athletics Federation of India - the Indian affiliate of the International Association of Athletics Federations (I.A.A.F.), which governs track and field. He told her he would forgo the usual urine and blood tests because no nurse was available, and would order an ultrasound instead. That confused Chand, but when she asked him about it, she recalls, he said it was routine.

Chand had no idea that her extraordinary showing in Taipei and at a national championship earlier that month had prompted competitors and coaches to tell the federation that her physique seemed suspiciously masculine: Her muscles were too pronounced, her stride was too impressive for someone who was only five feet tall. The doctor would later deny that the ultrasound was a response to those reports, saying he ordered the scan only because Chand had previously complained of chronic abdominal pain. She contends she never had any such pain.

Three days after the ultrasound, the federation sent a letter titled "Subject: Gender Verification Issue" to the Indian government's sports authority. "It has been brought to the notice of the undersigned that there are definite doubts regarding the gender of an Athlete Ms. Dutee Chand," the letter read. It also noted that in the past, such cases "have brought embarrassment to the fair name of sports in India." The letter requested the authorities perform a "gender verification test" on Chand.

Shortly after, Chand says, she was sent to a private hospital in Bangalore, where a curt woman drew her blood to measure her level of natural testosterone, though Chand had no idea that was what was being measured. Chand also underwent a chromosome analysis, an M.R.I. and a gynecological exam that she found mortifying. To evaluate the effects of high testosterone, the international athletic association's protocol involves measuring and palpating the clitoris, vagina and labia, as well as evaluating breast size and pubic hair scored on an illustrated five-grade scale.

The tests were meant to identify competitors whose chromosomes, hormones, genitalia, reproductive organs or secondary sex characteristics don't develop or align in the typical way. The word "hermaphrodite" is considered stigmatizing, so physicians and advocates instead use the term "intersex" or refer to the condition as D.S.D., which stands for either a disorder or a difference of sex development. Estimates of the number of intersex people vary widely, ranging from one in 5,000 to one in 60, because experts dispute which of the myriad conditions to include and how to tally them accurately. Some intersex women, for instance, have XX chromosomes and ovaries, but because of a genetic quirk are born with ambiguous genitalia, neither male nor female. Others have XY chromosomes and undescended testes, but a mutation affecting a key enzyme makes them appear female at birth; they're raised as girls, though at puberty, rising testosterone levels spur a deeper voice, an elongated clitoris and increased muscle mass. Still other intersex women have XY chromosomes and internal testes but appear female their whole lives, developing rounded hips and breasts, because their cells are insensitive to testosterone. They, like others, may never know their sex development was unusual, unless they're tested for infertility - or to compete in world-class sports.

When Chand's results came in a few days later, the doctor said her "male hormone" levels were too high, meaning she produced more androgens, mostly testosterone, than most women did. The typical female range is roughly 1.0 to 3.3 nanomoles of testosterone per liter of blood, about one-tenth that of typical males. Chand's level is not publicly known, but it was above the 10-nanomoles-per-liter threshold that the I.A.A.F. set for female competitors because that level is within the "male range." As a result, officials said, she could no longer race.

In the two years since, Chand has been at the center of a legal case that contests not only her disqualification but also the international policy her lawyers say discriminates against athletes with atypical sex development. For Chand, who had never heard the words "testosterone" or "intersex," it has been a slow and painful education. When she was first told she was being barred because of her testosterone level, she didn't understand anything the officials were saying. "I said, 'What have I done that is wrong?' " she told me by phone in May through a Hindi translator. "Then the media got my phone number and started calling me and asking about an androgen test, and I had no idea what an androgen test was. The media asked, 'Did you have a gender test?' And I said, 'What is a gender test?' "

No governing body has so tenaciously tried to determine who counts as a woman for the purpose of sports as the I.A.A.F. and the International Olympic Committee (I.O.C.). Those two influential organizations have spent a half-century vigorously policing gender boundaries. Their rationale for decades was to catch male athletes masquerading as women, though they never once discovered an impostor. Instead, the athletes snagged in those efforts have been intersex women - scores of them.

The treatment of female athletes, and intersex women in particular, has a long and sordid history. For centuries, sport was the exclusive province of males, the competitive arena where masculinity was cultivated and proven. Sport endowed men with the physical and psychological strength that "manhood" required. As women in the late 19th century encroached on explicitly male domains - sport, education, paid labor - many in society became increasingly anxious; if a woman's place wasn't immutable, maybe a man's role, and the power it entailed, were not secure either.

Well into the 20th century, women were discouraged from participating in sports. Some medical experts claimed that vigorous exercise would damage women's reproductive capacity and their fragile emotional state and would make them muscular, "mannish" and unattractive to men. Critics fretted that athletics would unbind women from femininity's modesty and self-restraint.

As women athletes' strength and confidence grew, some observers began to wonder if fast, powerful athletes could even be women. In the 1936 Berlin Olympics, the runners Stella Walsh of Poland and Helen Stephens of the United States were rumored to be male impostors because of their remarkable athleticism, "male-like" muscles and angular faces. After Stephens narrowly beat Walsh in the 100-meter dash and posted a world record, Stephens was publicly accused of being a man, by Walsh or Polish journalists - accounts vary. German Olympics officials had examined Stephens's genitals before the event and declared her female. Four decades later, in an unexpected twist, an autopsy of Walsh revealed she had ambiguous genitalia.

In 1938, the gender of an athlete was again in dispute. The German high-jumper Dora Ratjen, a former fourth-place Olympian who won a gold medal at the European Athletics Championship, was suddenly identified as male, prompting Germany to quietly return the medal. When Ratjen's case became public years later - he claimed that the Nazis pressured him to pose as a woman for three years - it validated the growing anxiety about gender fraud in athletics. But in 2009, the magazine Der Spiegel investigated medical and police records and found Ratjen had been born with ambiguous genitals but, at the midwife's suggestion, was raised as a girl, dressed in girls' clothes and sent to girls' schools. Dora lived as a female until two years after the 1936 Olympics, when police were alerted to a train traveler in women's clothes who looked suspiciously masculine. With relief so apparent that the police noted it in their report, Ratjen told them that despite his parents' claims, he had long suspected he was male. A police physician examined him and agreed, but reported that Ratjen's genitals were atypical. Ratjen changed his first name from Dora to Heinrich. But those details were unknown until recently, so for decades, Ratjen was considered a gender cheat.

By the mid-1940s, international sports administrators began requiring female competitors to bring medical "femininity certificates" to verify their sex. In the 1950s, many Olympics officials were so uneasy about women's participation that Prince Franz Josef of Liechtenstein, a member of the International Olympic Committee, spoke for many when he said he wanted to "be spared the unesthetic spectacle of women trying to look and act like men," writes Susan K. Cahn, a history professor at the University at Buffalo, in her book "Coming On Strong: Gender and Sexuality in 20th-Century Women's Sports." Others were particularly bothered by women in track and field because of the strained expressions on their faces during competition. Such female exertion violated the white middle-class ideal of femininity, as did the athletes' "masculinized" physiques, prompting Olympic leaders to consider eliminating those events for women.

In 1952, the Soviet Union joined the Olympics, stunning the world with the success and brawn of its female athletes. That year, women accounted for 23 of the Soviet Union's 71 medals, compared with eight of America's 76 medals. As the Olympics became another front in the Cold War, rumors spread in the 1960s that Eastern-bloc female athletes were men who bound their genitals to rake in more wins.

Though those claims were never substantiated, in 1966 international sports officials decided they couldn't trust individual nations to certify femininity, and instead implemented a mandatory genital check of every woman competing at international games. In some cases, this involved what came to be called the "nude parade," as each woman appeared, underpants down, before a panel of doctors; in others, it involved women's lying on their backs and pulling their knees to their chest for closer inspection. Several Soviet women who had dominated international athletics abruptly dropped out, cementing popular conviction that the Soviets had been tricking authorities. (More recently, some researchers have speculated that those athletes may have been intersex.)

Amid complaints about the genital checks, the I.A.A.F. and the I.O.C. introduced a new "gender verification" strategy in the late '60s: a chromosome test. Officials considered that a more dignified, objective way to root out not only impostors but also intersex athletes, who, Olympic officials said, needed to be barred to ensure fair play. Ewa Klobukowska, a Polish sprinter, was among the first to be ousted because of that test; she was reportedly found to have both XX and XXY chromosomes. An editorial in the I.O.C. magazine in 1968 insisted the chromosome test "indicates quite definitely the sex of a person," but many geneticists and endocrinologists disagreed, pointing out that sex was determined by a confluence of genetic, hormonal and physiological factors, not any one alone. Relying on science to arbitrate the male-female divide in sports is fruitless, they said, because science could not draw a line that nature itself refused to draw. They also argued that the tests discriminated against those whose anomalies provided little or no competitive edge and traumatized women who had spent their whole lives certain they were female, only to be told they were not female enough to participate.

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Dora Ratjen in 1937. Credit Ullstein Bild via Getty Images

One of those competitors was Maria José Martínez Patiño, a 24-year-old Spanish hurdler who was to run at the 1985 World University Games in Japan. The night before the race, a team official told her that her chromosome test results were abnormal. A more detailed investigation showed that although the outside of her body was fully female, Patiño had XY chromosomes and internal testes. But because of a genetic mutation, her cells completely resisted the testosterone she produced, so her body actually had access to less testosterone than a typical woman. Just before the Spanish national championships began, Spanish athletic officials told her she should feign an injury and withdraw from athletics permanently and without fuss. She refused. Instead, she ran the 60-meter hurdles and won, at which point someone leaked her test results to the press. Patiño was thrown off the national team, expelled from the athletes' residence and denied her scholarship. Her boyfriend and many friends and fellow athletes abandoned her. Her medals and records were revoked.

Patiño became the first athlete to formally protest the chromosome test and to argue that disqualification was unjustified. After nearly three years, the I.A.A.F. agreed that without being able to use testosterone, her body had no advantage, and it reinstated Patiño. But by then, her hopes for making the Olympics were dashed.

Dutee Chand was only 4 when she started running, tagging along with her sister, Saraswati, a competitive runner who liked to practice sprints along the local Brahmani River. Saraswati found training boring, so she recruited Dutee, 10 years her junior, to keep her company. For years, Dutee ran in bare feet - even on the village's mud-and-pebble streets - because she had to protect the only shoes she owned: flimsy rubber flip-flops that she knew her parents could not afford to replace.

When Dutee was about 7, her parents pressed her to stop running and learn to weave instead. But Saraswati argued that with Dutee's speed, she could earn more as a sprinter. Saraswati, who has since become a police officer, reminded her parents of the benefits her own running had brought to the family. Once the district government realized Saraswati's athletic potential, she, like other athletes, was given meat and chicken and eggs, food her family had not been able to afford. And she reminded them of the prize money she brought home whenever she did well in marathons. They agreed to let Dutee run.

Not long after, Saraswati used a string to measure Dutee's foot and took a bus to the nearest city, about 60 miles away, to find an affordable pair of sturdy sneakers for her sister. The ride took three hours, frequently picking up passengers carrying goats or chickens and large bundles. When Saraswati gave Dutee the sneakers the next morning, Saraswati told me over the phone through a translator, Dutee yelped. "She asked me what can happen if she runs wholeheartedly. She asked if she would go abroad like me, and said she had never sat in a bus or a train, and asked where the money will come from for her to go abroad. I said that 'if, with these shoes, you run well, you will be sent abroad from the money that will come to you, and not just that, but you'll also get a tracksuit. So run!' "

In 2006, 10-year-old Dutee was accepted into a state-sponsored sports program more than two hours from the family's home. Food, lodging and training were covered. She missed home but appreciated the dorm's electricity, running water and indoor toilets. And she was happy she could send prize money to her parents.

1936 Stella Walsh and Helen Stephens

That same year, though Dutee didn't know it, a catastrophe was unfolding for another Indian sprinter. Santhi Soundarajan, a 25-year-old from southern India, finished second in the 800 meters at the 2006 Asian Games in Doha, Qatar, all the more impressive given her roots as a member of India's impoverished "untouchable" caste. The previous decade, the I.O.C. and I.A.A.F. yielded to pressure by the medical and scientific community and stopped sex-testing every female athlete. But the groups retained the right to test an athlete's chromosomes when questions about her sex arose and to follow that with a hormone test, a gynecological exam and a psychological evaluation.

In Soundarajan's case, the media noted that she wasn't just fast; she also had a deep voice and a flat chest. The day after Soundarajan's race, the Athletics Federation of India drew her blood and examined her body. Some of her results were leaked to the media. Shortly after, Soundarajan was watching TV when she saw a news report that she had "failed" a sex test. Rejected by the local sports federations, stripped of her silver medal, tormented by ongoing scrutiny and unbearably embarrassed, she attempted suicide, reportedly by swallowing poison.

As Chand began competing in national athletics, another runner from a poor rural village, this time in South Africa, burst onto the international athletic stage. When Caster Semenya blew by her opponents in the 800-meter race at the 2009 African Junior Championships, her performance raised suspicions. Shortly after, sports officials tested her as she prepared for the World Athletics Championship. Unconcerned - she assumed the investigation was for doping - Semenya won gold again. Almost immediately, the fact that Semenya had been sex-tested was leaked to the press. Instead of attending what is normally the celebratory news conference, Semenya went into hiding. The I.A.A.F. spokesman Nick Davies announced that if Semenya was an impostor, she could be stripped of her medal. He added: "However, if it's a natural thing, and the athlete has always thought she's a woman or been a woman, it's not exactly cheating."

Fellow athletes, the press and commenters on social media scrutinized Semenya's body and made much of her supposed gender transgressions: her muscular physique, her deep voice, her flexed-biceps pose, her unshaved armpits, the long shorts she ran in instead of bikini shorts, in addition to her extraordinary speed. A story on Time magazine's website was headlined "Could This Women's World Champ Be a Man?" One of Semenya's competitors, Elisa Cusma of Italy, who came in sixth, said: "These kind of people should not run with us. For me, she is not a woman. She is a man." The Russian star runner Mariya Savinova reportedly sneered, "Just look at her." (The World Anti-Doping Agency would later accuse Savinova of using performance-enhancing drugs and recommend a lifetime ban.) The I.A.A.F. general secretary, Pierre Weiss, said of Semenya, "She is a woman, but maybe not 100 percent." Unlike India, South Africa filed a human rights complaint with the United Nations arguing that the I.A.A.F.'s testing of Semenya was "both sexist and racist." Semenya herself would later write in a statement, "I have been subjected to unwarranted and invasive scrutiny of the most intimate and private details of my being."

After nearly a year of negotiations (the details of which are not public) the I.A.A.F. cleared Semenya to run in 2010, and she went on to win the silver medal in the 2012 Olympics. She will be running in Rio. But the federation still faced condemnation over leaks, public smears and the very idea of a sex test. The I.A.A.F. maintained it was obliged to protect female athletes from having "to compete against athletes with hormone-related performance advantages commonly associated with men." In 2011, the association announced that it would abandon all references to "gender verification" or "gender policy." Instead, it would institute a test for "hyperandrogenism" (high testosterone) when there are "reasonable grounds for believing" that a woman may have the condition. Women whose testosterone level was "within the male range" would be barred. There were two exceptions: If a woman like Maria Patiño was resistant to testosterone's effects - or if a woman reduced her testosterone. This entails having her undescended testes surgically removed or taking hormone-suppressing drugs.

Not long after the policy went into effect, sports officials referred four female athletes from "rural or mountainous regions of developing countries" to a French hospital to reduce their high testosterone, according to a 2013 article in The Journal of Clinical Endocrinology & Metabolism. The authors, many of whom were physicians who treated the women, describe telling them that leaving in their internal testes "carries no health risk," but that removing them would allow the athletes to resume competition, though possibly hurt their performance. The women, who were between 18 and 21, agreed to the procedure. The physicians treating them also recommended surgically reducing their large clitorises to make them look more typical. The article doesn't mention whether they told their patients that altering their clitorises might impair sexual sensation, but it does say the women agreed to that surgery too.

Dutee Chand, left, at practice in Hyderabad, India. Credit Sohrab Hura/Magnum, for The New York Times

Chand was unaware of any controversy surrounding Semenya or other intersex athletes. Her gender concerns were much more immediate: She saw other 15-year-old girls becoming curvier and heard them talk about getting their periods. She asked her mother why her body wasn't doing the same thing, and trusted her answer: Chand's body would change when it was good and ready.

In 2012, Chand advanced to a national-level athletic training program, which in addition to food and lodging provided a stipend. At 16, she also became a national champion in the under-18 category, winning the 100 meters in 11.8 seconds. The next year, she won gold in the 100 meters and the 200 meters. In June 2014, she won gold yet again at the Asian championships in Taipei.

Not long after that, she received the call to go to Delhi and was tested. After her results came in, officials told her she could return to the national team only if she reduced her testosterone level - and that she wouldn't be allowed to compete for a year. The particulars of her results were not made public, but the media learned, and announced, that Chand had "failed" a "gender test" and wasn't a "normal" woman. For days, Chand cried inconsolably and refused to eat or drink. "Some in the news were saying I was a boy, and some said that maybe I was a transsexual," Chand told me. "I felt naked. I am a human being, but I felt I was an animal. I wondered how I would live with so much humiliation."

As news spread that Chand had been dropped from the national team, advocates encouraged her to fight back. Payoshni Mitra, an Indian researcher with a doctorate in gender issues in sport who had advocated on behalf of other intersex athletes, suggested Chand send a letter to the Athletics Federation of India, requesting her disqualification be reversed. "I have not doped or cheated," Chand said in Hindi, and Mitra, who would become Chand's government-appointed adviser, translated to English. "I am unable to understand why I am asked to fix my body in a certain way simply for participation as a woman. I was born a woman, reared up as a woman, I identify as a woman and I believe I should be allowed to compete with other women, many of whom are either taller than me or come from more privileged backgrounds, things that most certainly give them an edge over me."

Mitra and others also urged Chand to take her case to the international Court of Arbitration for Sport - the Supreme Court for sports disputes - arguing that the I.A.A.F.'s testosterone policy was discriminatory and should be rescinded. She agreed. Over four days in March 2015, a three-judge panel heard Chand's appeal, as a total of 16 witnesses, including scientists, sports officials and athletes, testified.

Female athletes, intersex and not, wondered just how this case would affect their lives. At the hearing, Paula Radcliffe, the British runner who holds the women's world record for the marathon, testified for the I.A.A.F., saying elevated testosterone levels "make the competition unequal in a way greater than simple natural talent and dedication." She added, "The concern remains that their bodies respond in different, stronger ways to training and racing than women with normal testosterone levels, and that this renders the competition fundamentally unfair."

1998, Veronica Brenner | The Canadian skier's ''femininity card'' from the Nagano games, which certifies her XX chromosomes. Credit Jessica Tang for The New York Times

Madeleine Pape, a 2008 Olympian from Australia, testified for Chand. Pape lost to Caster Semenya in the 2009 World Championships, Semenya's last race before her sex-test results were made public. Pape had heard runners complain that Semenya was a man or had male-like advantages, and she was angry that Semenya seemed to win so easily. "At the time, I felt that people like Caster shouldn't be allowed to compete," Pape told me. But in 2012, Pape began work on a sociology Ph.D. focusing on women in sport. "With my running days behind me, I had the space to think more critically about all that," she says. "Until that point, I had no idea that the science of sex differences is extremely contested and has shifted over time, as have the regulations in sports, which change but don't improve as they try to get at the same questions."

Just what role testosterone plays in improving athletic performance is still being debated. At the hearing, both sides agreed that synthetic testosterone - doping with anabolic steroids - does ramp up performance, helping male and female athletes jump higher and run faster. But they disagreed vehemently about whether the body's own testosterone has the same effect.

I.A.A.F. witnesses testified that logic suggests that natural testosterone is likely to work the way its synthetic twin does. They pointed to decades of I.A.A.F. and I.O.C. testing showing that a disproportionate number of elite female athletes, particularly in track and field, have XY chromosomes; by their estimates, the presence of the Y chromosome in this group is more than 140 times higher than it is among the general female population. Surely, witnesses for the I.A.A.F. argued, that overrepresentation indicated that natural testosterone has an outsize influence on athletic prowess.

Chand's witnesses countered that even if natural testosterone turns out to play a role in improving performance, testosterone alone can't explain the overrepresentation of intersex elite athletes; after all, many of those XY female athletes had low testosterone or had cells that lacked androgen receptors. At the Atlanta Games in 1996, one of the few times the I.O.C. allowed detailed intersex-related data to be released, seven of the eight women who were found to have a Y chromosome turned out to be androgen insensitive: Their bodies couldn't use the testosterone they made. Some geneticists speculate that the overrepresentation might be because of a gene on the Y chromosome that increases stature; height is clearly beneficial in several sports, though that certainly isn't a factor for Chand.

In court, the I.A.A.F. acknowledged that men's natural testosterone levels, no matter how high, were not regulated; the rationale, it said, was that there was no evidence that men with exceptionally high testosterone have a competitive advantage. Pressed by Chand's lawyer, the I.A.A.F. also conceded that no research had actually proved that unusually high levels of natural testosterone lead to unusually impressive sports performance in women either. Nor has any study proved that natural testosterone in the "male range" provides women with a competitive advantage commensurate with the 10 to 12 percent advantage that elite male athletes typically have over elite female athletes in comparable events. In fact, the I.A.A.F.'s own witnesses estimated the performance advantage of women with high testosterone to be between 1 and 3 percent, and the court played down the 3 percent figure, because it was based on limited, unpublished data.

Chand's witnesses also pointed out that researchers had identified more than 200 biological abnormalities that offer specific competitive advantages, among them increased aerobic capacity, resistance to fatigue, exceptionally long limbs, flexible joints, large hands and feet and increased numbers of fast-twitch muscle fibers - all of which make the idea of a level playing field illusory, and not one of which is regulated if it is innate.

Chand, with her longtime coach, Nagapuri Ramesh, working to qualify for Rio. Credit Sohrab Hura/Magnum, for The New York Times

Bruce Kidd, a former long-distance Olympic runner, told me in May that Olympians themselves sometimes joke that they're all freaks of nature, with one or another genetic abnormality that makes them great at what they do. Kidd, a Canadian who has long pushed for gender equity in sports, noted that there are also many external variables that influence performance: access to excellent coaching, training facilities, healthy nutrition and so on. "If athletic officials really want to address the significant factors affecting advantage, they should require all athletes to live in the same place, in the same level of wealth, with access to the same resources," he says. "Boy, oh, boy, there are so many unfair advantages many Olympians have, starting with who their parents are."

But the I.A.A.F. argued that testosterone is different from other factors, because it is responsible for the performance gap between the sexes. That gap is the very reason sports is divided by sex, the I.A.A.F. says, so regulating testosterone is therefore justified.

Chand's hearing, though, was about more than just testosterone. Implicitly, it questioned the decades of relentless scrutiny of female athletes - especially the most successful ones. Veronica Brenner, a Canadian who won a silver medal in freestyle skiing in 2002, told me she first learned that female Olympians had to pass a sex test when she arrived at the '98 Games in Nagano, Japan. "I said: 'Are you kidding?' I'd been competing my whole life, and my gender has never been questioned!" Brenner's test confirmed that she had XX chromosomes, and she was given what was commonly called a "femininity card" to prove she was the gender she claimed to be. But she was irked that despite the many advances of female athletes in the last half-century, powerful male athletes are celebrated and powerful female ones are suspect. "We'd hear comments all the time: 'She's really strong - she must be part guy.' "

Other critics see testosterone testing as simply the old "gender verification," the latest effort to keep out women who don't adhere to gender norms or have a standard female body. Katrina Karkazis, a bioethicist at Stanford University who is a leader of the international campaign against banning intersex athletes and who testified in Chand's case, says that if an athlete's androgen test shows she has high testosterone, she must undergo the same gynecological exam that has existed for decades. "The rationale behind the I.A.A.F.'s 'hyperandrogenism regulation' is to make it sound more scientifically justifiable and less discriminatory, but nothing in those exams has changed from the old policy except the name," she says. "It's still based on very rigid binary ideas about sex and gender."

Critics of the I.A.A.F. policy argue that if sports officials were truly concerned about fairness, they would quit policing a handful of women with naturally high testosterone and instead rigorously investigate athletes suspected of taking drugs that indisputably enhance performance. They note that in the last year, the I.A.A.F. has faced bribery and blackmail charges and widespread allegations that it intentionally ignored hundreds of suspicious blood tests.

Stéphane Bermon, an I.A.A.F. witness who took part in the efforts to identify females with high testosterone, acknowledged that doping was a significant threat to fairness but said that didn't negate the need to also regulate the participation of women with naturally high testosterone who may have an advantage. He offered an analogy: "Air pollution, like tobacco smoking, contributes to lung cancer, but one should never have to choose between these two before implementing prevention measures," he wrote in an email. "As a governing body, I.A.A.F. has to do its best to ensure a level playing field. ... These two topics are different but can lead to the same consequence, which is the impossibility for a dedicated athlete to compete and succeed against an opponent who benefits from an unfair advantage."

Dutee Chand Credit Sohrab Hura/Magnum, for The New York Times

Last July, the Court of Arbitration for Sport issued its ruling in Dutee Chand's case. The three-judge panel concluded that although natural testosterone may play some role in athleticism, just what that role is, and how influential it is, remains unknown. As a result, the judges said that the I.A.A.F.'s policy was not justified by current scientific research: "While the evidence indicates that higher levels of naturally occurring testosterone may increase athletic performance, the Panel is not satisfied that the degree of that advantage is more significant than the advantage derived from the numerous other variables which the parties acknowledge also affect female athletic performance: for example, nutrition, access to specialist training facilities and coaching and other genetic and biological variations."

The judges concluded that requiring women like Chand to change their bodies in order to compete was unjustifiably discriminatory. The panel suspended the policy until July 2017 to give the I.A.A.F. time to prove that the degree of competitive advantage conferred by naturally high testosterone in women was comparable to men's advantage. If the I.A.A.F. doesn't supply that evidence, the court said, the regulation "shall be declared void." It was the first time the court had ever overruled a sport-governing body's entire policy.

Chand was thrilled. "This wasn't just about me," she said, "but about all women like me, who come from difficult backgrounds. It is mostly people from poor backgrounds who come into running - people who know they will get food, housing, a job, if they run well. Richer people can pay their way to become doctors, engineers; poor people don't even know about their own medical challenges."

Chand hoped that the ruling would prompt the I.O.C. to suspend its testosterone policy, too, so she would be eligible to try to qualify for the Rio Games. After all, the I.O.C. policy - which also called on national Olympic committees to "investigate any perceived deviation in sex characteristics" - was based on the same science that the court deemed inadequate.

In November 2015, the I.O.C. established new parameters for dealing with gender. But it never actually addressed whether it would suspend its testosterone policy, as the I.A.A.F. was forced to do. That ambiguity left intersex athletes in limbo. Finally, in late February, the I.O.C. said it would not regulate women's natural testosterone levels "until the issues of the case are resolved." It urged the I.A.A.F. to come up with the evidence by the court's deadline so the suspended policy could be resurrected. It also said that to avoid discrimination, high-testosterone women who are ineligible to compete against women should be eligible to compete against men.

Advocates for intersex women were dismayed. "It's ridiculous," says Payoshni Mitra, the Indian researcher. "They say the policy is not for testing gender - but saying that a hyperandrogenic woman can compete as a man, not a woman, inherently means they think she really is a man, not a woman. It brings back the debate around an athlete's gender, publicly humiliating her in the process." Emmanuelle Moreau, head of media relations for the I.O.C., disagreed, writing in an email, "It is a question of eligibility, not gender or (biological) sex."

A separate section of the I.O.C. gender guidelines addressed a different group of atypical women (and atypical men): transgender athletes. Unlike the intersex section, the transgender section stresses the importance of human rights, nondiscrimination and inclusion. It eschews most of the I.O.C.'s former requirements, including that trans competitors have their ovaries or testicles removed and undergo surgery so their external genitalia matches their gender identity. In the new guidelines, female-to-male athletes face no restrictions of any kind; male-to-female athletes have some restrictions, including suppressing their testosterone levels below the typical male range. And once they've declared their gender as female, they can't change it again for four years if they want to compete in sports.

Reactions among trans advocates ran the gamut. Many trans advocates viewed the liberalized regulations as a victory. But some transwomen athletes who long ago had their testicles removed (and as a result, make virtually no testosterone) were unhappy with the policy; they argued that lifting the surgery requirement gave transwomen who still had testosterone-producing testicles an unfair advantage over transwomen who didn't. And still other advocates said that requiring transwomen to suppress their testosterone below 10 nanomoles is premised on the very same claim about testosterone that the court rejected - that naturally made testosterone is the primary cause of men's competitive advantage over women.

Without evidence that "male range" testosterone levels really do provide that advantage, some say it's premature to base a policy on speculation - especially one that requires people to transform their bodies. In May, the Canadian Center for Ethics in Sports, which manages the country's antidoping program and recommends ethics standards, issued trans-related guidelines for all Canadian sports organizations. The statement says policies that regulate eligibility, like those related to hormones, should be backed by defensible science. It adds, "There is simply not the evidence to suggest whether, or to what degree, hormone levels consistently confer competitive advantage." And yet it's hard to imagine that many female athletes would easily accept the idea of competing against transwomen athletes without those regulations in place.

Those debates are far from Chand's thoughts. Her focus now is on making the most of the window the ruling provides: allowing her to try to qualify for next month's Olympics without having to change her body. In the miserable months after her test results were revealed, Chand's training time and concentration were interrupted, and her hope of ever competing seemed out of reach. Once the ruling was issued, though, she returned to the Indian national team, and intensified her training for the 100 meters, the 200 meters and the 400-meter relay. In addition to working out six hours a day, she tries to relax with naps and Facebook. She has made frequent trips to nations holding qualifying competitions. In May, she competed in India, China and Taiwan; in June, in Kazakhstan and Kyrgyzstan. She has until July 11 to meet the I.O.C. time requirement.

She is painfully aware that if she doesn't make this summer's Olympics, she may not have another chance. The I.A.A.F. may still come up with evidence that satisfies the court and would exclude women like her from competing without altering their bodies. Chand's best shot to qualify for Rio is in the 100 meters, which she must complete in 11.32 seconds or less. She remains one-hundredth of a second short.
Note: On June 25, Dutee Chand qualified for the Rio Olympics, running the 100 meters in 11.30 seconds in Almaty, Kazakhstan, and breaking a national record for India. Later that day, she posted an even faster time of 11.24 seconds. She will be the first Indian woman to run the 100 meters in the Olympics since 1980.

Ruth Padawer is a contributing writer for the magazine.
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The Humiliating Practice of Sex-Testing Female Athletes

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Feature One day in June 2014, Dutee Chand was cooling down after a set of 200-meter sprints when she received a call from the director of the Athletics Federation of India, asking her to meet him in Delhi.

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Irreversible genital surgeries on intersex children still continue as parents feel pressured by doctors, leading to long-term harmful effects on the child as they grow up

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(Chicago, July 25, 2017) - Doctors in the United States continue to perform medically unnecessary surgeries that can inflict permanent harm on intersex children, Human Rights Watch and interACT said in a report released today. Despite decades of controversy over the procedures, doctors operate on children's gonads, internal sex organs, and genitals when they are too young to participate in the decision, even though the surgeries could be safely deferred.

The 160-page report, "'I Want to Be Like Nature Made Me': Medically Unnecessary Surgeries on Intersex Children in the US," examines the physical and psychological damage caused by medically unnecessary surgery on intersex people, who are born with chromosomes, gonads, sex organs, or genitalia that differ from those seen as socially typical for boys and girls. The report examines the controversy over the operations inside the medical community, and the pressure on parents to opt for surgery.

Once called "hermaphrodites" (a term now considered pejorative and outdated), intersex people are not rare, but they are widely misunderstood. Based on a medical theory popularized in the 1960s, doctors perform surgery on intersex children - often in infancy - with the stated aim of making it easier for them to grow up "normal." The results are often catastrophic, the supposed benefits are largely unproven, and there are rarely urgent health considerations requiring immediate, irreversible intervention.

"The devastation caused by medically unnecessary surgery on intersex infants is both physical and psychological," said Kimberly Zieselman, an intersex woman and executive director of interACT. "Despite decades of patient advocates putting the medical community on notice about the harm from these procedures, many doctors continue to present these surgeries to parents as good options."

As many as 1.7 percent of babies are different from what is typically called a boy or a girl. The chromosomes, gonads, internal, or external sex organs of these children differ from social expectations. Some intersex traits - such as atypical external genitalia - are apparent at birth. Others - such as gonads or chromosomes that do not match the expectations of the assigned sex - may manifest later in life, in some cases around puberty. A child can be raised as either sex without surgery. On the other hand, genital or gonadal surgeries on intersex children too young to declare their gender identity carry the risk of surgically assigning the wrong sex.

Surgery to remove gonads can amount to sterilization without the patient's consent, and then require lifelong hormone replacement therapy. Operations to alter the size or appearance of children's genitals risk incontinence, scarring, lack of sensation, and psychological trauma. The procedures are irreversible, nerves that are severed cannot regrow, and scar tissue can limit options for future surgery.

Medical protocols have evolved - in particular with an increasingly common use of multi-disciplinary teams that work on cases of "Differences of Sex Development." Most medical practitioners now acknowledge that parents may prefer to leave their child's body intact. A doctor who works on such a team told Human Rights Watch: "We're listening to the adult patients who are telling us that they feel they were mistreated and mutilated and that's a very powerful thing."

However, the field remains fraught with uneven, inadequate, and piecemeal standards of care - and broad disagreements among practitioners over how best to respect and protect the rights of their intersex patients. While certain surgical interventions on intersex children are undisputedly medically necessary, some surgeons in the US perform risky and medically unnecessary cosmetic surgeries on intersex children, often before they are even able to talk.

"The medical community has made progress in intersex care in recent decades, but medically unnecessary irreversible surgeries on children and infants remain common," said Kyle Knight, researcher at Human Rights Watch and author of the report. "The pressure to fit in and live a 'normal' life is real, but there is no evidence that surgery delivers on the promise of making that easier, and ample evidence that it risks causing irreversible lifelong harm."

United Nations human rights bodies have increasingly condemned countries around the world in recent years for failing to ban medically unnecessary surgery on intersex children. In a 2013 report, the United Nations special rapporteur on torture noted that, "Children who are born with atypical sex characteristics are often subject to irreversible sex assignment, involuntary sterilization, involuntary genital normalizing surgery ... leaving them with permanent, irreversible infertility and causing severe mental suffering."

In July 2017, three former US surgeons general wrote that they believed "there is insufficient evidence that growing up with atypical genitalia leads to psychosocial distress," and "while there is little evidence that cosmetic infant genitoplasty is necessary to reduce psychological damage, evidence does show that the surgery itself can cause severe and irreversible physical harm and emotional distress."

The report is based on in-depth interviews conducted by Human Rights Watch researcher Kyle Knight and Dr. Suegee Tamar-Mattis, a physician and Human Rights Watch research consultant, with 30 intersex adults, 2 intersex children, 17 parents of intersex children, and 21 healthcare practitioners including gynecologists, endocrinologists, urologists, psychologists, and other mental health providers who work with intersex people. The report also contains an extensive literature review, and features the available data on surgeries.

Several doctors told Human Rights Watch that while they were increasingly uncomfortable advising parents to choose these surgeries, the operations are still taking place in their clinics. Parents said they still feel pressure from doctors to elect these surgeries.

"The pediatricians are in a position of power. And if it's an issue of parents being scared, that is the problem that has to get solved. It's not really a matter of if you do surgery - that doesn't make any sense, that's not solving anything," an endocrinologist and medical professor told Human Rights Watch. "When we're trying to force people into cultural normative, hetero-normative situations, there's a high chance that we're going to make some major mistakes and harm people irreparably," said a gynecologist on a team for "differences in sex development."

Parents of an 8-year-old born with atypical genitals said: "The doctors told us it was important to have the surgery right away because it would be traumatic for our child to grow up looking different. What's more traumatic? This sort of operation or growing up a little different?"

These and other parents told Human Rights Watch that the most helpful resource in raising their intersex children was meeting other parents and intersex adults through support groups.

The experience of those who have undergone the surgery, along with principles of medical ethics, suggest that unless and until there is outcome data establishing that the medical benefits of specific surgical procedures on infants and young children outweigh the potential harm, they should not be used, interACT and Human Rights Watch said. At present and despite several decades' worth of surgeries, that evidence simply doesn't exist.

The US government and medical bodies should put an end to all surgical procedures that seek to alter the gonads, genitals, or internal sex organs of children with atypical sex characteristics too young to participate in the decision, when those procedures both carry a meaningful risk of harm and can be safely deferred, Human Rights Watch and interACT said.

"Parents of intersex children are often scared and confused about how best to protect their children from stigma," Zieselman said. "It's such a relief for them when they meet others who have the same intersex traits as their children and see that they have grown up healthy and happy."

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US: Harmful Surgery on Intersex Children

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Doctors in the United States continue to perform medically unnecessary surgeries that can inflict permanent harm on intersex children, Human Rights Watch and interACT said in a report released today. Despite decades of controversy over the procedures, doctors operate on children's gonads, internal sex organs, and genitals when they are too young to participate in the decision, even though the surgeries could be safely deferred.

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https://www.theguardian.com/sport/2018/sep/10/hannah-mouncey-hits-out-at-afl-as-she-withdraws-from-aflw-draft#img-1

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Short video about intersex children around the world and the debate surrounding whether or not they should be operated on before they are old enough to consent.

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Attitudes are changing to the medical practice, with some calling them limiting and unnecessary.

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So my thumbs show I have a male brain? Well, two fingers to that | Holly Baxter

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Holly Baxter: All this latest slice of paranoid gender-obsessed biology teaches is how attached science is to its pink and blue safety blankets

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The Five Sexes: Why Male and Female Are Not Enough

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The Five Sexes: Why Male and Female Are Not Enough

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The Five Sexes: Why Male and Female Are Not Enough

By Anne Fausto-Sterling

The Sciences March/April 1993, p. 20-24

Anne Fausto-Sterling is Professor of Biology and Women's Studies in the Department of Molecular and Cell Biology and Biochemistry at Brown University. Professor Fausto-Sterling's new book, entitled Sexing the Body: Gender Politics and the Construction of Sexuality, appeared in February, 2000.

In 1843 Levi Suydam, a twenty-three-year-old resident of Salisbury, Connecticut, asked the town board of selectmen to validate his right to vote as a Whig in a hotly contested local election. The request raised a flurry of objections from the opposition party, for reasons that must be rare in the annals of American democracy: it was said that Suydam was more female than male and thus (some eighty years before suffrage was extended to women) could not be allowed to cast a ballot. To settle the dispute a physician, one William James Barry, was brought in to examine Suydam. And, presumably upon encountering a phallus, the good doctor declared the prospective voter male. With Suydam safely in their column the Whigs won the election by a majority of one.

Barry's diagnosis, however, turned out to be somewhat premature. Within a few days he discovered that, phallus notwithstanding, Suydam menstruated regularly and had a vaginal opening. Both his/her physique and his/her mental predispositions were more complex than was first suspected. S/he had narrow shoulders and broad hips and felt occasional sexual yearnings for women. Suydam's "'feminine propensities, such as a fondness for gay colors, for pieces of calico, comparing and placing them together, and an aversion for bodily labor, and an inability to perform the same, were remarked by many," Barry later wrote. It is not clear whether Suydam lost or retained the vote, or whether the election results were reversed.

Western culture is deeply committed to the idea that there are only two sexes. Even language refuses other possibilities; thus to write about Levi Suydam I have had to invent conventions-- s/he and his/her -- to denote someone who is clearly neither male nor female or who is perhaps both sexes at once. Legally, too, every adult is either man or woman, and the difference, of course, is not trivial. For Suydam it meant the franchise; today it means being available for, or exempt from, draft registration, as well as being subject, in various ways, to a number of laws governing marriage, the family and human intimacy. In many parts of the United States, for instance, two people legally registered as men cannot have sexual relations without violating anti-sodomy statutes.

But if the state and the legal system have an interest in maintaining a two-party sexual system, they are in defiance of nature. For biologically speaking, there are many gradations running from female to male; and depending on how one calls the shots, one can argue that along that spectrum lie at least five sexes-- and perhaps even more.

For some time medical investigators have recognized the concept of the intersexual body. But the standard medical literature uses the term intersex as a catch-all for three major subgroups with some mixture of male and female characteristics: the so-called true hermaphrodites, whom I call herms, who possess one testis and one ovary (the sperm- and egg-producing vessels, or gonads); the male pseudohermaphrodites (the "merms"), who have testes and some aspects of the female genitalia but no ovaries; and the female pseudohermaphrodites (the "ferms"), who have ovaries and some aspects of the male genitalia but lack testes. Each of those categories is in itself complex; the percentage of male and female characteristics, for instance, can vary enormously among members of the same subgroup. Moreover, the inner lives of the people in each subgroup-- their special needs and their problems, attractions and repulsions -- have gone unexplored by science. But on the basis of what is known about them I suggest that the three intersexes, herm, merm and ferm, deserve to be considered additional sexes each in its own right. Indeed, I would argue further that sex is a vast, infinitely malleable continuum that defies the constraints of even five categories.

Not surprisingly, it is extremely difficult to estimate the frequency of intersexuality, much less the frequency of each of the three additional sexes: it is not the sort of information one volunteers on a job application. The psychologist John Money of Johns Hopkins University, a specialist in the study of congenital sexual-organ defects, suggests intersexuals may constitute as many as 4 percent of births. As I point out to my students at Brown University, in a student body of about 6,000 that fraction, if correct, implies there may be as many as 240 intersexuals on campus-- surely enough to form a minority caucus of some kind.

In reality though, few such students would make it as far as Brown in sexually diverse form. Recent advances in physiology and surgical technology now enable physicians to catch most intersexuals at the moment of birth.

The word hermaphrodite comes from the Greek name Hermes, variously known as the messenger of the gods, the patron of music, the controller of dreams or the protector of livestock, and Aphrodite, the goddess of sexual love and beauty. According to Greek mythology, those two gods parented Hermaphroditus, who at age fifteen became half male and half female when his body fused with the body of a nymph he fell in love with. In some true hermaphrodites the testis and the ovary grow separately but bilaterally, in others they grow together within the same organ, forming an ovo-testis. Not infrequently, at least one of the gonads functions quite well, producing either sperm cells or eggs, as well as functional levels of the sex hormones-- androgens or estrogens. Although in theory it might be possible for a true hermaphrodite to become both father and mother to a child, in practice the appropriate ducts and tubes are not configured so that egg and sperm can meet.

In contrast with the true hermaphrodites, the pseudohermaphrodites possess two gonads of the same kind along with the

usual male (XY) or female (XX) chromosomal makeup. But their external genitalia and secondary sex characteristics do not match their chromosomes. Thus merms have testes and XY chromosomes, yet they also have a vagina and a clitoris, and at puberty they often develop breasts. They do not menstruate, however. Ferms have ovaries, two X chromosomes and sometimes a uterus, but they also have at least partly masculine external genitalia. Without medical intervention they can develop beards, deep voices and adult-size penises.

The embryological origins of human hermaphrodites clearly fit what is known about male and female sexual development. The embryonic gonad generally chooses early in development to follow either a male or a female sexual pathway; for the ovo-testis, however, that choice is fudged. Similarly, the embryonic phallus most often ends up as a clitoris or a penis, but the existence of intermediate states comes as no surprise to the embryologist. There are also uro-genital swellings in the embryo that usually either stay open and become the vaginal labia or fuse and become a scrotum. In some hermaphrodites, though, the choice of opening or closing is ambivalent. Finally, all mammalian embryos have structures that can become the female uterus and the fallopian tubes, as well as structures that can become part of the male sperm-transport system. Typically either the male or the female set of those primordial genital organs degenerates, and the remaining structures achieve their sex-appropriate future. In hermaphrodites both sets of organs develop to varying degrees.

Intersexuality itself is old news. Hermaphrodites, for instance, are often featured in stories about human origins. Early biblical scholars believed Adam began life as a hermaphrodite and later divided into two people-- a male and a female -- after falling from grace. According to Plato there once were three sexes -- male, female and hermaphrodite -- but the third sex was lost with time.

Both the Talmud and the Tosefta, the Jewish books of law, list extensive regulations for people of mixed sex. The Tosefta expressly forbids hermaphrodites to inherit their fathers' estates (like daughters), to seclude themselves with women (like sons) or to shave (like men). When hermaphrodites menstruate they must be isolated from men (like women); they are disqualified from serving as witnesses or as priests (like women), but the laws of pederasty apply to them.

In Europe a pattern emerged by the end of the Middle Ages that, in a sense, has lasted to the present day: hermaphrodites were compelled to choose an established gender role and stick with it. The penalty for transgression was often death. Thus in the 1600s a Scottish hermaphrodite living as a woman was buried alive after impregnating his/her master's daughter.

For questions of inheritance, legitimacy, paternity, succession to title and eligibility for certain professions to be determined, modern Anglo-Saxon legal systems require that newborns be registered as either male or female. In the U.S. today sex determination is governed by state laws. Illinois permits adults to change the sex recorded on their birth certificates should a physician attest to having performed the appropriate surgery The New York Academy of Medicine on the other hand, has taken an opposite view. In spite of surgical alterations of the external genitalia, the academy argued in 1966, the chromosomal sex remains the same. By that measure, a person's wish to conceal his or her original sex cannot outweigh the public interest in protection against fraud.

During this century the medical community has completed what the legal world began-- the complete erasure of any form of embodied sex that does not conform to a male-female, heterosexual pattern. Ironically, a more sophisticated knowledge of the complexity of sexual systems has led to the repression of such intricacy.

In 1937 the urologist Hugh H. Young of Johns Hopkins University published a volume titled Genital Abnormalities, Hermaphrodites and Related Adrenal Diseases. The book is remarkable for its erudition, scientific insight and open-mindedness. In it Young drew together a wealth of carefully documented case histories to demonstrate and study the medical treatment of such "accidents of birth." Young did not pass judgment on the people he studied, nor did he attempt to coerce into treatment those intersexuals; who rejected that option. And he showed unusual evenhandedness in referring to those people who had sexual experiences as both men and women as "Practicing hermaphrodites."

One of Young's more interesting cases was a hermaphrodite named Emma who had grown up as a female. Emma had both a penis-size clitoris and a vagina, which made it possible for him/ her to have "normal" heterosexual sex with both men and women. As a teenager Emma had had sex with a number of girls to whom s/he was deeply attracted; but at the age of nineteen s/he had married a man. Unfortunately, he had given Emma little sexual pleasure (though he had had no complaints), and so throughout that marriage and subsequent ones Emma had kept girlfriends on the side. With some frequency s/he had pleasurable sex with them. Young describes his subject as appearing "to be quite content and even happy." In conversation Emma occasionally told him of his/her wish to be a man, a circumstance Young said would be relatively easy to bring about. But Emma's reply strikes a heroic blow for self-interest:

Would you have to remove that vagina? I don't know about that because that's my meal ticket. If you did that, I would have to quit my husband and go to work, so I think I'll keep it and stay as I am. My husband supports me well,

and even though I don't have any sexual pleasure with him, I do have lots with my girlfriends.

Yet even as Young was illuminating intersexuality with the light of scientific reason, he was beginning its suppression. For his book is also an extended treatise on the most modem surgical and hormonal methods of changing intersexuals, into either males or females. Young may have differed from his successors in being less judgmental and controlling of the patients and their families, but he nonetheless supplied the foundation on which current intervention practices were built.

By 1969, when the English physicians Christopher J. Dewhurst and Ronald R. Gordon wrote The Intersexual Disorders, medical and surgical approaches to intersexuality had neared a state of rigid uniformity. It is hardly surprising that such a hardening of opinion took place in the era of the feminine mystique-- of the post-Second World War flight to the suburbs and the strict division of family roles according to sex. That the medical consensus was not quite universal (or perhaps that it seemed poised to break apart again) can be gleaned from the near-hysterical tone of Dewhurst and Gordon's book, which contrasts markedly with the calm reason of Young's founding work. Consider their opening description of an intersexual newborn:

One can only attempt to imagine the anguish of the parents. That a newborn should have a deformity ... [affecting] so fundamental an issue as the very sex of the child ... is a tragic event which immediately conjures up visions of a hopeless psychological misfit doomed to live always as a sexual freak in loneliness and frustration.

Scientific dogma has held fast to the assumption that without medical care hermaphrodites are doomed to a life of misery. Yet there are few empirical studies to back up that assumption, and some of the same research gathered to build a case for medical treatment contradicts it. Francies Benton, another of Young's practicing hermaphrodites, "had not worried over his condition, did not wish to be changed, and was enjoying life." The same could be said of Emma, the opportunistic hausfrau. Even Dewhurst and Gordon, adamant about the psychological importance of treating intersexuals; at the infant stage, acknowledged great success in "changing the sex" of older patients. They reported on twenty cases of children reclassified into a different sex after the supposedly critical age of eighteen months. They asserted that all the reclassifications were "successful," and they wondered then whether reregistration could be "recommended more readily than [had] been suggested so far."

The treatment of intersexuality in this century provides a dear example of what the French historian Michel Foucault has called biopower. The knowledge developed in biochemistry, embryology, endocrinology, psychology and surgery has enabled physicians to control the very sex of the human body. The multiple contradictions in that kind of power call for some scrutiny. On the one hand, the medical "management" of intersexuality certainly developed as part of an attempt to free people from perceived psychological pain (though whether the pain was the patient's, the parents' or the physician's is unclear). And if one accepts the assumption that in a sex-divided culture people can realize their greatest potential for happiness and productivity only if they are sure they belong to one of only two acknowledged sexes, modern medicine has been extremely successful.

On the other hand, the same medical accomplishments can be read not as progress but as a mode of discipline. Hermaphrodites have unruly bodies. They do not fall naturally into a binary classification; only a surgical shoehorn can put them there. But why should we care if a "woman," defined as one who has breasts, a vagina, a uterus and ovaries and who menstruates, also has a clitoris large enough to penetrate the vagina of another woman? Why should we care if there are people whose biological equipment enables them to have sex "naturally" with both men and women? The answers seem to lie in a cultural need to maintain clear distinctions between the sexes. Society mandates the control of intersexual bodies because they blur and bridge the great divide. Inasmuch as hermaphrodites literally embody both sexes, they challenge traditional beliefs about sexual difference: they possess the irritating ability to live sometimes as one sex and sometimes the other, and they raise the specter of homosexuality.

But what if things were altogether different? Imagine a world in which the same knowledge that has enabled medicine to intervene in the management of intersexual patients has been placed at the service of multiple sexualities. Imagine that the sexes have multiplied beyond currently imaginable limits. It would have to be a world of shared powers. Patient and physician, parent and child, male and female, heterosexual and homosexual-- all those oppositions and others would have to be dissolved as sources of division. A new ethic of medical treatment would arise, one that would permit ambiguity in a culture that had overcome sexual division. The central mission of medical treatment would be to preserve life. Thus hermaphrodites would be concerned primarily not about whether they can conform to society but about whether they might develop potentially life-threatening conditions -- hernias, gonadal tumors, salt imbalance caused by adrenal malfunction -- that sometimes accompany hermaphroditic development. In my ideal world medical intervention for intersexuals would take place only rarely before the age of reason; subsequent treatment would be a cooperative venture between physician, patient and other advisers trained in issues of gender multiplicity.

All that and more amply explains why intersexual children are generally squeezed into one of the two prevailing sexual categories. But what would be the psychological consequences of taking the alternative road-- raising children as unabashed intersexuals? On the surface that tack seems fraught with peril. What, for example, would happen to the intersexual child amid the unrelenting cruelty of the school yard? When the time came to shower in gym class, what horrors and humiliations would await the intersexual as his/her anatomy was displayed in all its nontraditional glory? In whose gym class would s/he register to begin with? What bathroom would s/he use? And how on earth would Mom and Dad help shepherd him/her through the mine field of puberty?

In the past thirty years those questions have been ignored, as the scientific community has, with remarkable unanimity, avoided contemplating the alternative route of unimpeded intersexuality, But modem investigators tend to overlook a substantial body of case histories, most of them compiled between 1930 and 1960, before surgical intervention became rampant. Almost without exception, those reports describe children who grew up knowing they were intersexual (though they did not advertise it) and adjusted to their unusual status. Some of the studies are richly detailed-- described at the level of gym-class showering (which most intersexuals avoided without incident); in any event, there is not a psychotic or a suicide in the lot.

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The Five Sexes: Why Male and Female Are Not Enough

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The Five Sexes: Why Male and Female Are Not Enough By Anne Fausto-Sterling The Sciences March/April 1993, p. 20-24 Anne Fausto-Sterling is Professor of Biology and Women's Studies in the Department of Molecular and Cell Biology and Biochemistry at Brown University.

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When Juliet Swire gave birth to her third son in February 2014, doctors told her not to tell anyone he'd been born. She didn't announce Jack's arrival for weeks - not even to close family and friends.

Jack was born with both male and female anatomy, with ovarian and testicular tissue, and genitals that could belong to either a boy or a girl. He has one of at least 40 congenital variations, known collectively as disorders of sexual development (DSD), or intersex traits. It was months before Juliet and her husband, Will, were told Jack's specific diagnosis, of mixed gonadal dysgenesis. While they waited, all his parents knew was that Jack's sex couldn't be determined at birth, and that their doctors needed time to assign it.

"One of the beautiful parts of having a baby is being able to share the joy that this tiny, newborn person has entered the world," Juliet says. "We could have announced that our baby had been born with complications that mean we don't know if he's a boy or a girl. But the doctors took that away from us without any explanation." By encouraging them to keep Jack a secret, the doctors made them feel there was something shameful about his condition, she says. "It set the precedent for how other people were going to perceive it."

I'd assumed that XX is a girl and XY is a boy. People don't know there are variations, so when they occur it's freakish

Jack's specific diagnosis is rare, but being born with a blend of female and male characteristics is surprisingly common: worldwide, up to 1.7% of people have intersex traits, roughly the same proportion of the population who have red hair, according to the Office of the United Nations High Commissioner for Human Rights. The British charity DSD Families estimates that around 130 babies born in this country each year need investigations before their sex is assigned. Other people may have problems with their hormones that aren't visible at birth.

Jack's parents knew he was different before he was born, when a routine scan couldn't determine if he was a boy or a girl. Juliet was referred to a consultant at the local hospital, followed by meetings with geneticists and neonatologists, blood tests and an amniocentesis. She was told her baby was genetically male, but that this didn't necessarily make him a boy. "It was very hard. I'd just assumed that XX is girl and XY is boy," Juliet says. "Because people don't know there are variations, when they occur it's a freakish thing. But actually, he is just a normal child."

Bouncing around the living room of their home in the West Midlands, Jack looks completely ordinary. With mousy, curly hair, a runny nose and a toothy smile, he clambers over Juliet and chucks a green football at me, oblivious to what his mother is telling me.

"My entire pregnancy, I'd worried that I wasn't going to be able to love my baby because it wasn't a he and it wasn't a she," she recalls. But when Jack was born, he was blue and floppy. "Although it was awful at the time, it was the best thing that could have happened: I would have done anything to have made sure he was breathing again." Her eyes fill with tears. "Quite quickly, he was crying. The relief was unbelievable. He was a baby and he needed feeding. Making sure that he was cared for was my priority, not poking around in his nappy."

Then someone from Bounty (a baby merchandising company whose sales reps, controversially, are allowed on maternity wards to collect mothers' details for marketing purposes and to sell photographs) paid her a visit when Jack was a day old; Will had just gone home to rest. She told Juliet she was there to take pictures of the baby: was it a boy or a girl? "We had no idea. Because I was tired and emotional, I just said, 'Oh, he's a boy.' She then got a blue blanket and a blue teddy and a label that said 'I'm a boy', and put it on him to take photographs. She never even asked permission to be there. When she left, it was the biggest meltdown I'd had yet."

The Swires say they still feel let down by the team who were supposed to be looking after them - not just the photographs, but being advised by doctors not to announce Jack's birth, by the fact their midwife didn't read Juliet's notes before delivering him, by the fact other people working in the hospital were not stopped from asking them the sex of their new baby. Most of all, they felt isolated by how little medical professionals knew about disorders of sexual development. "The midwives have never heard of it. Our GPs have never heard of it. A&E doctors don't know, nurses don't know. It's rare - but it's not that rare."

***

When it comes to wider public awareness of what it is like to be intersex, there is almost none. While the transgender rights movement gathers momentum, and a growing number of people are choosing to identify as "non-binary" - neither male nor female - those who are born outside the physical categories of male and female sex have found it more difficult to have their voices heard. They are atomised, connected only by condition-specific support groups rather than united under a broader intersex umbrella. The terminology itself is fiercely contested: some find the "disorders of sexual development" label deeply offensive, as it implies a defect rather than a natural state of being. Others, often parents like Juliet, prefer DSD and reject the label intersex as "negative and sensationalising".

But a movement is beginning to emerge. Social media has presented fresh opportunities for older people to connect, seeing their difference as variations to be embraced rather than defects to be corrected. A new generation is campaigning so that children born like them aren't forced into biological categories: either socially, by being made to identify as male or female on birth certificates and other official paperwork; or on the operating table.

The sex on a baby's birth certificate is generally based on what their genitals look like, but this is only part of what makes a boy a boy and a girl a girl: there are also the ovaries or testes, the mix of hormones, the pattern of the chromosomes. Variations in any of these physical characteristics means bodies don't fall into the binary categories that make up conventional sex definitions. Sometimes these variations can lead to medical complications, such as infertility or hormone imbalances, but most intersex babies are physically healthy. Not all have ambiguous genitalia, and some don't discover their condition for years: girls with complete androgen insensitivity syndrome (CAIS) might not realise they are genetically male until they reach their teens and their periods don't arrive.

"Normalising" surgery to make very young children look more typically male or female has been standard practice for decades. Malta became the first country to outlaw non-consensual medical interventions on intersex people (including those too young to give informed consent) in 2015. In January this year, the Chilean government issued guidelines to doctors opposing corrective surgery, allowing them to refuse a parent and not face legal consequences. The parents of an adopted intersex boy are currently suing doctors and social services in South Carolina in the United States for removing his penis and testes at 16 months, even though it was not medically necessary - potentially opening the floodgates for future litigation. But in the UK, US and Australia, there is currently no national law or guidance on corrective surgery: it is up to the individual hospital or practitioner to decide.

For the Swires' doctors, there was no question as to whether or not Jack should have surgery. "It was assumed that we would do certain things the whole way along," Juliet says. "We weren't given an option." Their neonatologist was "very confident that operating on children to make them more normal was the right thing to do. His confidence gave us confidence."

One doctor described it as your baby being born with an extra nose on their face. Would you leave it there, or fix it?

After blood tests to confirm Jack's genetic makeup and assess his hormones, and scans to look at his internal organs, it was decided that he should be assigned male. But the scans turned out to have given a false result: when he was nine months old, Jack was discovered to have a uterus and fallopian tubes, albeit ones that could never produce children. These were immediately removed, because doctors said they posed a high risk of malignancy and cancer; he has had two further operations that will make him pass more easily as male. ("If you imagine labia - they stitched that together," Juliet explains. "They called it 'zipping it up'.") At the same time, they corrected Jack's hypospadias, a condition that meant his urethra opened at the base of his penis, moving it further up so he could pee more like a boy. He has further operations to come.

The pressure of making choices on Jack's behalf has been tough on the Swires. "I'm confident we have made the right decision," says Juliet. "I don't see him as strikingly different to his brothers. But there are flashes of doubt - generally around surgery days, when we are making the decision to make him a certain way. Based on all the information we've been given - but still, we are the ones making the decisions." She adds: "One of the doctors described it to us as your baby being born with an extra nose on their face. Would you leave it there, or would you fix it?"

As if it were a deformity?

"Yes. Cleft lip - that's essentially a cosmetic thing; would you repair it? Yes, you would. It is a defect, it's not how it's meant to look."

The Swires' decision was made without the support of psychologists or counsellors, or even family. Juliet gave up her job in childcare to take care of Jack full time, as even very close relatives have found his condition hard to accept: she says she can't trust them to change his nappy without making him feel uncomfortable.

Juliet looks at Jack as he vaults across the sofa. "There is no option to be genderless in this society," she says. Would it have made a difference if there were? "It might have done," she replies immediately. "If you could say you could be male, female or something else, and that was a normal thing to do in unusual circumstances, then it might have made a difference. But you go with the majority, you go with what you think is right. While he is this young, I am the person making those decisions and I've got to be confident about them. If he did identify as female as he gets older, I'd want him to know I was confident that I was doing the right thing for him every step of the way."

Dawn Vago has grown up with the consequences of having surgery to "correct" an intersex variation as a child. Now 35, she is genetically male but has always looked entirely female. She has CAIS, complete androgen insensitivity syndrome: her body has XY chromosomes but is unable to respond to male sex hormones, so she developed female genitalia. Internally, she was born with testes instead of ovaries, and no uterus.

Warm and self-assured, Vago lives in Cheshire when she's not working as an entertainer on a cruise ship. She is one of only a few British intersex people prepared to speak publicly on the issue. "My parents were told not to tell me, that I wouldn't understand and I wouldn't fit into society if I knew the shameful secret about myself," she says. "They wanted me to live an open and honest life, so they told me when I was five years old." Dawn's parents were told by doctors that she would get cancer if her testes weren't removed, so she had a full gonadectomy aged eight. "They said I would not survive puberty if I did not have the operation, and that wasn't true."

The advice regarding the cancer risk has since changed; it is now thought to be minimal and to affect adults, not children - meaning the decision to remove the testes or ovaries can be left until people are old enough to make it themselves. Vago says the synthetic hormones she now has to take have left her with a higher risk of developing breast cancer than she would have had of developing testicular cancer. "Because my body wasn't receiving the healthy hormones that it would have produced, and through mismanagement of my synthetic hormones, my body started to deteriorate." By the time she was in her mid-20s, Vago had developed osteoporosis and broken 11 bones. She believes choices about medical intervention, be that surgery or hormones, should be left until the individual is old enough to make an informed decision.

Doctors said I'd never find a man to love me and have my own family. I adore that I'm married and starting a family

Vago is living proof that intersex people can live successful lives while being open about being born outside traditional male and female categories. We're speaking a few days after she has had a bid to adopt approved. "Doctors told my parents that I would never find a man who would love me, and I would never have my own family. I absolutely adore the fact that I am married and about to start a family. It proves you control your own life."

Like the Swires, Vago's family learned to live in a state of isolation. Doctors had told them their child was totally unique: there were no other families to share experiences with, no support group to join. It wasn't until she was 22 that she found out she wasn't alone. "I was very angry at the time, because I'd spent the last 22 years not knowing where I fitted into society - only to find out there was a huge community out there that I could have connected with."

Dawn is now co-director of IntersexUK, a campaign group founded in 2011 to end stigma around intersex variations, and to fight for equality and protection of intersex people. Top of its list of 33 demands is: "To put an end to mutilating and 'normalising' practices such as genital surgeries, psychological and other medical treatments through legislative and other means." It is one of several British organisations now lobbying for corrective surgery to be outlawed in the UK. In March, IntersexUK and other campaigners met with members of the Scottish parliament to make their case.

"We promote bodily autonomy and fully informed consent," Vago explains. "The surgeries that are happening on intersex children are for the most part cosmetic. Most are about making the child conform to society's ideology of what male and female is. The child's body is the child's body to decide what they want to do with themselves." IntersexUK doesn't suggest an age when it considers children old enough to give informed consent; British transgender children aren't offered the option of gender reassignment surgery until they are at least 17.

"It's akin to female genital mutilation, or as we term it, intersex genital mutilation, IGM," Vago says. "And it is happening in the UK right now." On 9 June, IntersexUK was instrumental in getting the UN Committee on the Rights of the Child to reprimand the UK for allowing "medically unnecessary surgeries and other procedures on intersex children before they are able to provide their informed consent". The report found that such surgery "can cause severe physical and psychological suffering".

In 2013, the special rapporteur to the United Nations Human Rights Council's report into torture and other cruel, inhuman or degrading treatment called on member states to ban "forced genital-normalising" surgery. Last year, the Council of Europe's Commissioner for Human Rights demanded an "urgent" end to "unnecessary medical treatment and surgery of intersex individuals without their consent". In March, campaigners Joe Holliday and Ela Xora chained themselves to the Houses of Parliament and called for a UK government inquiry into corrective surgery.

"It is becoming increasingly likely that the government will have to move on this, just as they moved on the gender recognition act and the same sex marriage act," says Dr Jay Hayes-Light, director of the UK Intersex Association, which lobbied MSPs alongside IntersexUK earlier this year. "This is long overdue."

Born intersex and given medical treatment to assign him female, a sex he didn't want to be, Hayes-Light has lived as a man since he was 19. Like Vago, he is campaigning for the right not to choose a gender on birth certificates, as the non-binary movement is. "You can't create a woman with a scalpel and a tablet," he says, plainly. "Medical practitioners view intersex as something that needs to be fixed. We are regarded as deformed, somehow in deficit anatomically, and therefore the way to fix it is to cobble us together into what they deem to be an acceptable format, instead of allowing us to exist in society."

Hayes-Light recognises that it is often the fear of social rejection that motivates parents to choose surgery for their children; they just want them to be "normal", and not forced to be the vanguards of a political movement. "The opinion of other people should not be a catalyst, but it does matter," he says. "Parents need help, guidance and advice to deal with it."

***

When Ruth Spencer gave birth two years ago in the East Midlands, the midwife told her she had a boy. He was checked by the paediatrician; Ruth and her husband were given the paperwork for his birth certificate. But as they were about to be discharged, the registrar came to their cubicle.

"She asked where the birth certificate letter was. I said it was in the car - we were getting ready to leave - and she said, 'I'm sorry, you're not going to be able to leave, because we don't know if your baby's a little boy or a girl.'" With only curtains to separate them from the rest of the ward, everyone around them could hear.

"It was our first child, it was such an amazing experience - and then they just pulled the rug out from beneath us. We told family we'd had a boy, we had named him. Luke was born at 5.30am, and they didn't say anything to us until 4pm." It was another two days before Luke had an ultrasound; while the Spencers waited, each new shift of midwives asked them if they'd had a boy or a girl. "Such simple things could have made it so much easier," Ruth remembers.

Luke is now two and the family still don't have a diagnosis. Genetically male, Luke was born with a small penis, undescended testicles and other variations that mean he has a DSD. "At some point in the not so distant past, boys born with the genitalia our son had would have been reassigned female," says Ruth.

He has had two operations: one was medically necessary to preserve his fertility; the other was performed to avoid discomfort for him in the future, Ruth says. Choosing to go ahead with the procedures wasn't easy. "All my trust is in these doctors and yet there are such conflicting opinions on what should be done. We were of a mind to leave all treatment for as long as possible, so that we could involve him. No one ever asked us, are you OK with this? It was just, this is what we're going to do. Abnormality, disorder, problem - these are all the words that are thrown at you. It makes it out to be something wrong. It might not be the standard, but it's still nature." She sighs. "It's such a huge decision to make."

In theory, parents like Ruth and Juliet should be assigned specialist psychological support to help them make these decisions, but provision around the country is patchy and underfunded. Even where experienced psychologists are available, they are stretched.

Dr Julie Alderson, a clinical psychologist at University Hospitals Bristol NHS Foundation Trust, has been working with parents of children with DSD since the late 1990s. Almost every family she meets has felt ashamed or embarrassed after their treatment on the maternity ward, she tells me. While tests and surgical techniques have changed over the course of her career, she still hears parents describing "the same problems, the same worries, the same purgatory of time" as they did 20 years ago.

In Bristol, Alderson works alongside an interdisciplinary team of surgeons, geneticists and endocrinologists. Her role is to offer families space to think. "All of the very well-meaning, passionate and caring healthcare professionals involved have got strong views about what's the right thing, and they present options for all kinds of treatment in a way that is leading, in the nicest possible way. People don't feel that they are making a decision: it's very easy to accept what's offered and what feels like it's being recommended. I'm saying to the families, what are you actually hoping for for your child? And how much will surgery deliver that?" Parents may hope surgery will allow their children to be more comfortable in their bodies, but a child raised to have a positive identity about being different might be more secure than one who has scars and needs regular hospital checkups, she argues.

The surgical team at Bristol Children's Hospital who work with Alderson know that an emerging human rights campaign is focusing on their work. "We're doing it less and less," says consultant paediatric urologist Guy Nicholls. "We have become more mindful that, whatever surgery you do, you are preserving fertility for the future and not doing something early for a cosmetic reason which may then jeopardise function in the future. Any surgery for this sort of problem is a little bit of a compromise - you try and include the parents and manage their expectations, making them realise we can't achieve normality, no matter how much we want to or how hard we try."

I kept looking at my baby thinking, this can't be. I hadn't heard of intersex. If I had, I'd have been more prepared

Nicholls' words may be couched in the language of "abnormalities" and "problems", but he says that's how most parents view disorders of sexual development. "Surgeons are under constant pressure from parents to 'sort it out'. They want their child to be normal. They want the problem to go away. That's absolutely understandable. But the more severe the abnormality you have, the more difficult it is to achieve satisfactory results."

If surgery is successful enough for people to pass as their chosen sex without any complications, they don't want to broadcast that they've had it, Nicholls points out. "We don't tend to hear from the people who do very well. You hear a lot from the people who have had a lot of problems." These are problems largely with sexual function, and a need for further surgery as a child grows older. "They relate to procedures that were done some time ago, which are probably slightly different from what many of us are doing now. We like to think we are causing less scarring, fewer problems for the future - but we won't know for 20 years."

Mark Woodward, a paediatric surgeon and urologist who works alongside Nicholls, agrees. "A small group of people who have had surgery and are understandably unhappy will detract from a genuine picture of a whole load of people not being unhappy. It's tricky to write off surgery on the basis of that."

Surgery in infancy is more straightforward than later in life, Woodward argues: tissues are easier to operate on and heal better, and the distances to bridge are smaller. Performing an operation before a baby can remember the trauma spares them the distress of going through it as a teenager. Plus, no one has expertise in operating on young people old enough to give informed consent.

"If everyone is too worried about doing the wrong thing by these children now, and we say, 'Let's leave it until they're 15,' who's going to do the surgery? It isn't going to be a paediatric urologist. It's not like there is a generation of surgeons out there who will have had any experience of this very niche surgery. I just worry that people will become too scared to do anything for fear of doing the wrong thing, and then be putting off a problem that will be a real surgical challenge. Surgeons are getting less experienced, if anything." While the Swires' doctors did not hesitate to recommend surgery, others are increasingly reluctant.

There is little data on the wellbeing of intersex children who don't have surgery, with not enough studies and too few cases for meaningful conclusions to be drawn. Deciding not to operate on a child comes with some consequences, just as choosing surgery does: raising a child with ambiguous anatomy in a world where a binary understanding of sex still rules is not easy.

At the moment, both options are available to British parents: to refuse or opt for surgery. And while a ban on "normalising" surgery is not imminent, the intersex rights movement is already having an impact on medical attitudes and surgical decisions: a growing number of British parents are beginning to choose for their children not to have any surgery.

Tanya Dart's daughter Clara, now five, has CAIS, the same condition as Dawn Vago. Doctors in the hospital where Tanya gave birth noticed something looked different as soon as she was born. "I'd never had a baby before, I just thought that's what newborn babies looked like," Tanya smiles. She is sitting in the living room of her London home, speaking to me over Skype in the brief window while she has a break from Clara and her seven-month-old brother. The doctors told Tanya she had a baby girl, but wrote in her notes that Clara was "ambiguous".

Like Ruth, Tanya was told about her daughter's condition behind a curtain on the maternity ward. "It was about 9pm and my husband had gone home. The registrar put his hands on his hips and started whispering, 'You know, these could be testes. I hope you understand - this could be a boy.'" She shakes her head in disbelief. "It was like he was sharing a piece of gossip. I kept looking at my baby thinking, this can't be. I hadn't heard of intersex or DSD. If I'd heard anything about it, I'd have been more prepared."

The Darts were referred to Great Ormond Street Hospital, where they met a psychologist and an endocrinologist. "They explained it so well. They made everything clear and they were compassionate, so I didn't even think about surgery. The option was there, but the way they were explaining to us, it was quite clear that we could leave it. It made the choice easy."

They know great challenges lie ahead for Clara. They haven't decided how and when they are going to tell her. "We are following advice from the hospital that it has to be a very gradual process, starting from when we think is best," Tanya says. They know that Clara will never be able to get pregnant, and have explained to her that some women can't have babies of their own and can choose to adopt if they want to. Clara thinks that sounds like a very kind thing to do.

But their greatest worry is about how Clara might be perceived in a world that is unforgiving of difference. "Why is there stigma attached? In terms of being able to talk to others, and not be petrified about what people will think of us. I feel that everyone would take their children away from my child and say, 'Don't play with her' if they knew." Tanya pauses. "I want as many people as possible to know about these conditions. I want it to be the kind of thing that people can talk about. I hope there will be a day in my daughter's lifetime where everyone knows about intersex, and it's no big deal."

* Some names have been changed.

This article was amended on Saturday 2 July. In the standfirst, the word 'gender' was replaced with the word 'sex'.
Topics

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'We don't know if your baby's a boy or a girl': growing up intersex

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When Juliet Swire gave birth to her third son in February 2014, doctors told her not to tell anyone he'd been born. She didn't announce Jack's arrival for weeks - not even to close family and friends. Jack was born with both male and female anatomy, with ovarian and testicular tissue, and genitals that could belong to either a boy or a girl.

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The way we think about biological sex is wrong

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The way we think about biological sex is wrong

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Emily Quinn is an intersex speaker who talks about the way that society puts people into these categories of gender from before birth - and can cause people to try and fix these 'problems' that aren't actually problems that need to be fixed

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The way we think about biological sex is wrong | Emily Quinn