A person holds a transgender pride flag as people gather on Christopher Street outside the Stonewall Inn for a rally to mark the 50th anniversary of the Stonewall Riots in New York, June 28, 2019. (Photo by Angela Weiss/AFP/Getty Images).
Many people would be surprised to learn that one out of every 100 people in the U.S. are intersex, meaning they don’t have bodies that conventional medicine would classify as “male” or “female.” As far as it’s known, this is not a new phenomenon — but this population has been largely invisible throughout much of American history.
Before there was a widely known intersex movement, intersex bodies were largely treated by the medical establishment and the broader society as a problem to be solved.
According to Hida Viloria, intersex educator and author of Born Both: An Intersex Life and the upcoming The Spectrum of Sex: The Science of Male, Female and Intersex, when European colonists first set foot in America, they encountered Native Americans who were intersex, as well as those we would describe today as “trans” and “gender-nonconforming.”
“However, the Europeans quickly sought to eradicate the accepted and valued social position of sex and gender diverse people, through documented persecution and executions, thereby enforcing a male/female only sex and gender system which did not accept the existence of intersex people,” said Viloria.
White Americans identifying as intersex started to gain attention in the 1600s, when “gender fraud” trials began taking place. These trials would usually culminate in forced reassignment to one gender and potentially the invalidation of marriages or inheritance rights, leading many people to conceal their intersex status.
Because people usually hid that they were intersex, many historical figures could have been intersex without anyone knowing. Recent analyses of the remains of General Casimir Pulaski, for example, show that he may have had two X chromosomes and congenital adrenal hyperplasia (CAH), which causes fetuses to develop male traits.
The first recorded American who faced scrutiny over their ambiguous genitalia was Thomas/Thomasine Hall, who had lived as both a woman and a man at various points. In 1629, the Virginia General Court examined Hall’s genitals repeatedly and eventually came to the conclusion that Hall needed to wear both male and female clothing.
“The more typical response encouraged people born with genital ambiguity to choose one gender and live with it, without moving back and forth,” said Elizabeth Reis, a professor of gender and bioethics at the Macaulay Honors College, City University of New York, and the author of Bodies in Doubt: An American History of Intersex.
But at that time, not everyone even went to the doctor, so intersex people weren’t subject to the medical attention they are today.
The first known surgery aimed at correcting anatomical incongruity occurred in 1849, and these surgeries continued in an ad hoc fashion for adults until they later became the standard of care for children in the 1950s.
“These surgeries were frequently motivated by worries about homosexuality,” added Reis. “In deciding the sex of their patients, doctors wanted happy endings, hoping to see their patients get married (to a member of the opposite sex). In fact, many cases of genital surgery seemed designed to make the genitals serve the doctors’ perception of patients’ sexual and marital requirements.”
The belief back then was that “there’s this truth that everyone is male or female, and the issue with intersex folks is that they may appear to be atypically sexed, but if we do more research and are able to explore, we’ll see that they are typically sexed in one way or another,” said Catherine Clune-Taylor, assistant professor of feminist science and technology studies in the department of women’s studies at San Diego State University.
Evolution of classification, preferred semantics
German pathologist Edwin Klebs created a system in 1876 that classified intersex people into three groups: true hermaphrodites (with both ovarian and testicular tissue), female pseudohermaphrodites (with only ovarian tissue), and male pseudohermaphrodites (with only testicular tissue).
“But what keeps happening is, as technology advances, it’s increasingly revealed that whatever the old definition of sex is is untrue,” said Clune-Taylor.
For example, due to advances in microscopy and anesthetics, researchers came to understand that people could have one testicle and one ovary. As the fields of embryology and endocrinology emerged, doctors became more hesitant about assigning a baby a sex.
“By the 1920s, you’re already starting to see clinicians say, ‘Oh, this is more complicated,’” concludes Clune-Taylor. “It hits its height by the mid-’40s because, during World War II, a lot of surgical techniques are more refined.”
In the 1950s, New Zealand psychologist John Money introduced the “optimum gender of rearing” model for treatment of intersex people, which involved predicting a baby’s future gender identity, performing surgery in accordance with that prediction, and raising the child with rigid gender norms. This model was used up until 2006, says Clune-Taylor, but it was widely criticized for causing surgeries that did not align with the child’s future gender identity.
In 2006, doctors began using the “disorders of sex development” treatment model, which is similar to the optimum gender of rearing model but more cautious in suggesting surgery. However, research has shown that intersex surgeries have continued at about the same rate since 2006.
According to Clune-Taylor, childhood surgeries have had many negative consequences for intersex people. They are typically done with only parents’ consent, as doctors and parents often believe it’s best to do the surgeries while the patients are still children, and people sometimes grow up to identify with a gender other than the one doctors assign them.
Because vaginoplasty is technically easier than phalloplasty, these physical limitations often determine what sex doctors assign a baby. Patients also face physical risks such as incontinence, sterility, scarring, hormonal imbalances, and loss of sexual sensation, says Reis.
“Activists today are trying to convince physicians and parents that people should have the right to make these difficult and personal decisions about their own bodies when they’re able to consent for themselves, fully understanding the risks, benefits, and alternatives,” says Reis. “There is no harm in waiting until children born with intersex traits are older to see what they want done (if anything at all) to their bodies.”
In that aim, they’ve been largely successful. The American Academy of Family Physicians issued a policy in 2018 opposing medically unnecessary intersex surgeries, and the United Nations has called intersex surgery a human rights violation.
Current threats, legality
California and Connecticut both proposed bans on intersex surgery this year, but medical stakeholders and some parents of intersex children have challenged these proposals, says Viloria. Even so, many parents now keep their intersex children as they are rather than forcing surgery on them, she says.
People are also pushing for legal recognition of intersex people. In 2015, Navy veteran Dana Zzyym, associate director of the Intersex Campaign for Equality, sued the federal government for refusing to issue them a passport. The lawsuit asks that intersex people be legally recognized as a third sex. After a ruling in Zzyym’s favor by a Colorado federal judge, the suit is in the court of appeals. In the meantime, 14 states have allowed people to designate a third gender on their IDs.
In addition, intersex people have gained more visibility in the media, Viloria points out. British model and James Bond actress Caroline Cossey, for example, wrote in her 1991 memoir that she was assigned male at birth due to Klinefelter syndrome, which can cause someone to have male traits at birth but develop female traits during puberty.
The language with which we talk about intersex people has changed as well. Until the 1990s, intersex people were referred to as “hermaphrodites.” But intersex activists have since pushed back against that term because “it conjures mythical creatures instead of real people and is thus offensive,” says Reis. The traditional definition of a hermaphrodite is someone born with “a perfect set of both male and female genital organs,” she adds, “which actually never happens.”
Today, many organizations include “I” for intersex in the acronym LGBTQIA+.
“Since then, the number of people living openly as intersex has increased exponentially,” added Viloria. “Under increasingly mainstream, equality focused social perspectives, many now acknowledge intersex people as simply one of the many communities of our diverse human species.”