Sex assignment

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Sex assignment (also known as gender assignment [1] [2] ) is the discernment of an infant's sex, usually at birth. [3] Based on an inspection of the baby's external genitalia by a relative, midwife, nurse, or physician, sex is assigned without ambiguity in 99.95% of births. In the remaining cases (1 in 2000), additional diagnostic steps are required and sex assignment is deferred. [4] Sex also may be determined prior to birth through prenatal sex discernment. [5]

Contents

The number of births where the baby is intersex—where their sex characteristics do not fit typical definitions of male and female—is estimated to be between 0.018% and 1.7%. [6] [7] [8] While some intersex conditions can lead to genital ambiguity (about 0.02% to 0.05% of births [4] ), in others genitalia can clearly be identified as either male or female. [9] In the latter cases, an intersex condition might not be recognized at birth. [10]

Generally, parents and society, as well as governments and healthcare systems, assume that a person's gender identity will develop according to the sex assigned at birth; this is known as being cisgender. While this is the case for a majority of people, for a significant number assigned sex and gender identity do not align; this is known as being transgender. [2] [11]

The sex assignment of an intersex individual may also contradict their future gender identity. [12] If available, knowledge about the gender identity that a majority of people with the specific intersex condition develop is considered in sex assignment. [13] Assignments might later be adjusted as a person grows up. [2] Reinforcing sex assignments through surgical or hormonal interventions without informed consent is considered by the Office of the United Nations High Commissioner for Human Rights to violate the individual's human rights. [14] [15]

Terminology

Sex assignment is the discernment of an infant's sex at birth, usually based on the phenotypic sex. It is also referred to as gender assignment. [2] [16]

According to the Diagnostic and Statistical Manual of Mental Disorders maintained by the American Psychiatric Association, the result is referred to as birth-assigned sex or birth-assigned gender, while the terms assigned sex and assigned gender include later assignments or reassignments during infancy and early childhood, as they are common in intersex people.

The terminology used in the manual has evolved over its editions. The third edition of the manual used the term "anatomic sex". [17] The term assigned sex was introduced into the manual in the fourth edition, published in 1994. [18] However, the terms biological sex and natal gender were also used in the fourth and fifth editions, as well as the term assigned sex. The manual was updated to only use the terminology of sex assignment in the 2022 text revision. [2] [19]

The 2006 consensus statement on intersex conditions likewise uses the terms assigned sex and assigned gender. [20]

Sex is assigned as either male or female, [2] [11] giving rise to the following terminology:

Assigned male at birth (AMAB)
a person of any age and irrespective of current gender whose sex was assigned as "male" at birth. Synonyms: male assigned at birth (MAAB) and designated male at birth (DMAB). [21] [22]

Assigned female at birth (AFAB)
a person of any age and irrespective of current gender whose sex was assigned as "female" at birth. Synonyms: female assigned at birth (FAAB) and designated female at birth (DFAB). [21] [22]
AGAB
Acronym for assigned gender at birth. [23]

Assignment in cases of infants with intersex traits, or cases of trauma

Observation or recognition of an infant's sex may be complicated in the case of intersex infants and children and in cases of early trauma. In such cases, the infant may be assigned male or female, and may receive intersex surgery to confirm that assignment. These medical interventions have increasingly been seen as a human rights violation due to their unnecessary nature and the potential for lifelong complications. [24] [25] [14]

The Phall-O-Meter satirizes clinical assessments of appropriate clitoris and penis length at birth, and the definition of ambiguous genitalia. It is based on research published by Suzanne Kessler. Phall-O-meter', Intersex Society of North Wellcome L0031936.jpg
The Phall-O-Meter satirizes clinical assessments of appropriate clitoris and penis length at birth, and the definition of ambiguous genitalia. It is based on research published by Suzanne Kessler.

Cases of trauma include the famous John/Joan case, where sexologist John Money claimed successful reassignment from male to female of a 17-month old boy whose penis was destroyed during circumcision. However, this claim was later shown to be largely false. The subject, David Reimer, later identified as a man. [26]

The number of births with ambiguous genitals is in the range of 1 in 2,000 to 1 in 4,500 (0.05% to 0.02%). [4] Typical examples would be an unusually prominent clitoris in an otherwise apparently typical girl, or complete cryptorchidism in an otherwise apparently typical boy. In most of these cases, a sex is tentatively assigned and the parents told that tests will be performed to confirm the apparent sex. Typical tests in this situation might include a pelvic ultrasound to determine the presence of a uterus, a testosterone or 17α-hydroxyprogesterone level, and/or a karyotype. In some of these cases a pediatric endocrinologist is consulted to confirm the tentative sex assignment. The expected assignment is usually confirmed within hours to a few days in these cases.

Some infants are born with enough ambiguity that assignment becomes a more drawn-out process of multiple tests and intensive education of the parents about sexual differentiation. In some of these cases, it is clear that the child will face physical difficulties or social stigma as they grow up, and deciding upon the sex of assignment involves weighing the advantages and disadvantages of either assignment. Intersex activists have criticised "normalising" procedures performed on infants and children, who are unable to provide informed consent. [25]

History

The words Sex assignment came into use in the late 1950s and early 1960s. [27]

In European societies, Roman law, post-classical canon law, and later common law, referred to a person's sex as male, female, or hermaphrodite, with legal rights as male or female depending on the characteristics that appeared most dominant. Under Roman law, a hermaphrodite had to be classed as either male or female. [28] The 12th-century Decretum Gratiani states that "Whether a hermaphrodite may witness a testament, depends on which sex prevails". [29] [30] The foundation of common law, the 16th Century Institutes of the Lawes of England , described how a hermaphrodite could inherit "either as male or female, according to that kind of sexe which doth prevaile." [31] [32] Legal cases where sex assignment was placed in doubt have been described over the centuries.

With the medicalization of intersex, criteria for assignment have evolved over the decades, as clinical understanding of biological factors and diagnostic tests have improved, as surgical techniques have changed and potential complications have become clearer, and in response to the outcomes and opinions of adults who have grown up with various intersex conditions.

Before the 1950s, assignment was based almost entirely on the appearance of the external genitalia. Although physicians recognized that there were conditions in which the apparent secondary sexual characteristics could develop contrary to the person's sex, and conditions in which the gonadal sex did not match that of the external genitalia, their ability to understand and diagnose such conditions in infancy was too poor to attempt to predict future development in most cases.

In the 1950s, endocrinologists developed a basic understanding of the major intersex conditions such as congenital adrenal hyperplasia (CAH), androgen insensitivity syndrome, and mixed gonadal dysgenesis. The discovery of cortisone allowed survival of infants with severe CAH for the first time. New hormone tests and karyotypes allowed more confident diagnosis in infancy and prediction of future development.

Sex assignment became more than choosing a sex of rearing, but also began to include surgical treatment. Undescended testes could be retrieved. A greatly enlarged clitoris could be amputated to the usual size, but attempts to create a penis were unsuccessful. John Money and others controversially believed that children were more likely to develop a gender identity that matched sex of rearing than might be determined by chromosomes, gonads, or hormones. The resulting medical model was termed the "Optimal gender model". [33]

Challenges to requirements for sex assignment

In recent years, the perceived need to legally assign sex is increasingly being challenged by transgender, transsexual, and intersex people. [34] [35] A report for the Dutch Ministry of Security and Justice states "Gender increasingly seems to be perceived as a 'sensitive' identity feature, but so far is not regarded, nor protected as such in privacy regulations". [34] Australian government guidelines state that "departments and agencies that collect sex and/or gender information must not collect information unless it is necessary for, or directly related to, one or more of the agency's functions or activities" [36]

Sex registration was introduced in the Netherlands in 1811 due to gender-specific rights and responsibilities, such as military conscription. [34] Many gender-specific provisions in legislation no longer exist, but the provisions remain for rationales that include "speed of identification procedures". [34]

Related Research Articles

Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their gender identity—their personal sense of their own gender—and their sex assigned at birth. The term replaced the previous diagnostic label of gender identity disorder (GID) in 2013 with the release of the diagnostic manual DSM-5. The condition was renamed to remove the stigma associated with the term disorder.

Gender identity is the personal sense of one's own gender. Gender identity can correlate with a person's assigned sex or can differ from it. In most individuals, the various biological determinants of sex are congruent, and consistent with the individual's gender identity. Gender expression typically reflects a person's gender identity, but this is not always the case. While a person may express behaviors, attitudes, and appearances consistent with a particular gender role, such expression may not necessarily reflect their gender identity. The term gender identity was coined by psychiatry professor Robert J. Stoller in 1964 and popularized by the controversial psychologist John Money.

<span class="mw-page-title-main">Intersex medical interventions</span> Performed to modify atypical or ambiguous genitalia

Intersex medical interventions, also known as intersex genital mutilations (IGM), are surgical, hormonal and other medical interventions performed to modify atypical or ambiguous genitalia and other sex characteristics, primarily for the purposes of making a person's appearance more typical and to reduce the likelihood of future problems. The history of intersex surgery has been characterized by controversy due to reports that surgery can compromise sexual function and sensation, and create lifelong health issues. Timing, evidence, necessity and indications for surgeries in infancy, adolescence or adult age have been controversial, associated with issues of consent.

<span class="mw-page-title-main">History of intersex surgery</span> Aspect of history

The history of intersex surgery is intertwined with the development of the specialities of pediatric surgery, pediatric urology, and pediatric endocrinology, with our increasingly refined understanding of sexual differentiation, with the development of political advocacy groups united by a human qualified analysis, and in the last decade by doubts as to efficacy, and controversy over when and even whether some procedures should be performed.

<span class="mw-page-title-main">True hermaphroditism</span> Intersex condition including both ovarian and testicular tissue

True hermaphroditism, sometimes referred to as ovotesticular syndrome, is an outdated term for an intersex condition in which an individual is born with both ovarian and testicular tissue. Commonly, one or both gonads is an ovotestis containing both types of tissue.

Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent due to a mismatch between their assigned sex and gender identity. The diagnostic label gender identity disorder in children (GIDC) was used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) until it was renamed gender dysphoria in children in 2013 with the release of the DSM-5. The diagnosis was renamed to remove the stigma associated with the term disorder.

<span class="mw-page-title-main">Partial androgen insensitivity syndrome</span> Medical condition

Partial androgen insensitivity syndrome (PAIS) is a condition that results in the partial inability of the cell to respond to androgens. It is an X linked recessive condition. The partial unresponsiveness of the cell to the presence of androgenic hormones impairs the masculinization of male genitalia in the developing fetus, as well as the development of male secondary sexual characteristics at puberty, but does not significantly impair female genital or sexual development. As such, the insensitivity to androgens is clinically significant only when it occurs in individuals with a Y chromosome. Clinical features include ambiguous genitalia at birth and primary amenhorrhoea with clitoromegaly with inguinal masses. Müllerian structures are not present in the individual.

<span class="mw-page-title-main">Disorders of sex development</span> Medical conditions involving the development of the reproductive system

Disorders of sex development (DSDs), also known as differences in sex development, diverse sex development and variations in sex characteristics (VSC), are congenital conditions affecting the reproductive system, in which development of chromosomal, gonadal, or anatomical sex is atypical.

<span class="mw-page-title-main">Intersex</span> Atypical congenital variations of sex characteristics

Intersex people are individuals born with any of several sex characteristics including chromosome patterns, gonads, or genitals that, according to the Office of the United Nations High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies".

<span class="mw-page-title-main">Intersex human rights</span> Human rights for intersex people

Intersex people are born with sex characteristics, such as chromosomes, gonads, or genitals, that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies."

<span class="mw-page-title-main">Intersex people in history</span>

Intersex, in humans and other animals, describes variations in sex characteristics including chromosomes, gonads, sex hormones, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies". Intersex people were historically termed hermaphrodites, "congenital eunuchs", or even congenitally "frigid". Such terms have fallen out of favor, now considered to be misleading and stigmatizing.

<span class="mw-page-title-main">Legal recognition of intersex people</span>

Intersex people are born with sex characteristics, such as chromosomes, gonads, or genitals that, according to the United Nations Office of the High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies".

<span class="mw-page-title-main">Intersex people and religion</span>

Intersex people are born with sex characteristics, such as chromosomes, gonads, or genitals that, according to the UN Office of the High Commissioner for Human Rights, "do not fit typical binary notions of male or female bodies".

<span class="mw-page-title-main">Intersex and LGBT</span> Relationship between different sex and gender minorities

Intersex people are born with sex characteristics that "do not fit the typical definitions for male or female bodies". They are substantially more likely to identify as lesbian, gay, bisexual, or transgender (LGBT) than the non-intersex population, with an estimated 52% identifying as non-heterosexual and 8.5% to 20% experiencing gender dysphoria. Although many intersex people are heterosexual and cisgender, this overlap and "shared experiences of harm arising from dominant societal sex and gender norms" has led to intersex people often being included under the LGBT umbrella, with the acronym sometimes expanded to LGBTI. Some intersex activists and organisations have criticised this inclusion as distracting from intersex-specific issues such as involuntary medical interventions.

<span class="mw-page-title-main">Timeline of intersex history</span> Overview of notable events in the timeline of intersex history

The following is a timeline of intersex history.

<span class="mw-page-title-main">Intersex rights in Australia</span> Overview of intersex peoples rights in Australia

Intersex rights in Australia are protections and rights afforded to intersex people through statutes, regulations, and international human rights treaties, including through the Sex Discrimination Act 1984 (Cth) which makes it unlawful to discriminate against a person based upon that person's intersex status in contexts such as work, education, provision of services, and accommodation.

<span class="mw-page-title-main">Intersex rights in the United States</span> Overview of intersex peoples rights in the United States of America

Intersex people in the United States have some of the same rights as other people, but with significant gaps, particularly in protection from non-consensual cosmetic medical interventions and violence, and protection from discrimination. Actions by intersex civil society organizations aim to eliminate harmful practices, promote social acceptance, and equality. In recent years, intersex activists have also secured some forms of legal recognition. Since April 11, 2022 US Passports give the sex/gender options of male, female and X by self determination.

<span class="mw-page-title-main">Intersex rights in the United Kingdom</span> Overview of intersex peoples rights in the United Kingdom

Intersex people in the United Kingdom face significant gaps in legal protections, particularly in protection from non-consensual medical interventions, and protection from discrimination. Actions by intersex civil society organisations aim to eliminate unnecessary medical interventions and harmful practices, promote social acceptance, and equality in line with Council of Europe and United Nations demands. Intersex civil society organisations campaign for greater social acceptance, understanding of issues of bodily autonomy, and recognition of the human rights of intersex people.

<span class="mw-page-title-main">United States partial military ban on intersex people</span> United States military ban on some intersex people

The (DoDI) 6130.03, 2018, section 5, 13f and 14m is the writing which bars persons with "true hermaphroditism", "pseudohermaphroditism" and "pure gonadal dysgenesis" from serving in the United States Armed Forces. The three are all intersex conditions and are as of now considered to be medically incompatible with military service in the United States. "DoDI" stands for "Department of Defense Instruction," the 6130.03 instruction concerns "Medical Standards for Appointment, Enlistment, or Induction in the Military Services" in the Armed Forces of the United States. Section 5 focuses on disqualifying conditions of the male and female reproductive system, on the female page the subheader 13 and paragraph f name true hermaphroditism, pseudohermaphroditism and pure gonadal dysgenesis specifically, and on the male page the subheader 14 and paragraph m also name exactly true hermaphroditism, pseudohermaphroditism and pure gonadal dysgenesis, respectively. There is no differentiation made between males and females with these conditions. Many doctors, medical professionals and intersex advocates find the terms hermaphroditism to be outdated and stigmatized, therefore it and its derivative words are seldom used in the 2000s, with the word hermaphrodite itself being considered a slur when used against a human.

<span class="mw-page-title-main">Definitions of intersex</span>

The definition of what is an intersex condition is controversial. Ambiguous genitalia occurs in roughly 0.05% of all births, and atypical genitalia occurs in 0.5% of all births, usually caused by masculinization or feminization during pregnancy, these conditions range from full androgen insensitivity syndrome, to ovotesticular syndrome although the definition of "normal" genitalia is largely arbitrary. 1.7% of people are born with a difference of sexual development, such as those with Klinefelter's syndrome. The DSD was specifically made to be as inclusive to all atypical sexual development, not all conditions within the DSD effect individuals to the same extent. Most intersex activism is based around the end of unnecessary medical interventions on intersex youth which attempt to assign an arbitrary sex and gender binary often causing physical harm with no input from the child. Intersex conditions are usually expanded to include the DSD more generally. While 0.5% of all births are born with atypical genitalia only 0.05% of births are medically treated, or considered to be "truly" ambiguous generally.

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