On the word "hermaphrodite"
The word "hermaphrodite" is a stigmatizing and misleading word
Victorian doctors believed that the gonads were the seat of "true sex,"
in the absence of any knowledge of genetics, endocrinology, or embryology -- which categorized people as "male pseudohermaphrodite," "female pseudohermaphrodite,"
It's time to eliminate this quaint Victorianism from modern medical practice
Genetics for Theologians: Male/Female A Polydimensional Continuum (archived)
Roberta M. Meehan, PhD., Greeley, Colorado
College Science Educator and Biological Science Writer
Discussion # 1
We are discussing "male/female"
terms apply to the human condition and not as they apply to linguistics and semantics
My plan is to present a series of commentaries on my perceptions of this male/female continuum
To begin this discussion on Chromosomes and the Continuum, I think it is important to first define a few terms
"SEX" usually refers to reproductive differences
"Gender" is one of those terms that really should be divided into about 3 or 4 different words. However, we are stuck with one word that has a variety of overlapping meanings. In biology, "gender" usually refers to man/woman -- and is thus a more restrictive term than "sex". However, "gender" can be used synonymously with "sex" when referring to humans and other higher level species ... gender is a grammatical identification and means masculine/feminine but has very little to do with male/female -- except in some cases
SOCIETAL SEX (often called by any of several other names) is determined after birth -- i.e., how is the person raised (male or female or intersex), what are the social and cultural mores, etc. For our purposes, societal sex deals with society's identification of the individual
Could such a person (particularly the XO/XY person) be ordained?
... As a sidelight, the Olympic Committee (as of 1991) no longer tests for chromosome compliments but does rely on visual examination to determine whether a person is male or female
There probably are quite a few priests who are XXY
Genetic anomalies do not make human beings less human, though sometimes these anomalies make them less reproductively capable. And why should reproductive capability be a criterion for ministerial capability? Sexual dichotomy does NOT exist for the survival of the individual.
Sexual dichotomy does NOT exist either for the ministerial goals of the individual or the ministerial goals of the species. Sexual dichotomy does NOT exist for the perpetuation of the Kingdom of God in any way other than to assure that all life is included. Sexual dichotomy is a biological phenomenon assuring the survival of the species; it is not a prerequisite for ministry -- which is a human (though not biological) phenomenon.
Androgen Insensitivity Syndrome Support Group
"We are an international support group providing information and support to young people and adults with complete and partial Androgen Insensitivity Syndrome, and to parents of AIS youngsters. We also support those affected by Swyer’s syndrome (XY gonadal dysgenesis), 5 alpha reductase deficiency, Leydig Cell Hypoplasia, Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, Mullerian dysgenesis, Mullerian duct aplasia, vaginal atresia, and other related conditions."
The UK Intersex Association
The United Kingdom Intersex Association (UKIA) is an education, advocacy, campaigning and support organisation which works on behalf of Intersex people.
Intersex people are individuals whose anatomy or physiology differ from contemporary cultural stereotypes of what constitute typical male and female.
A Reassessment of sex assignment
Susan J. Bradley et al., Hospital for Sick Children, Toronto, Ontario, Canada, PEDIATRICS Vol. 102 No. 1 July 1998, p. e9
[for Professionals mainly]
Experiment of Nurture: Ablatio Penis at 2 Months, Sex Reassignment at 7 Months, and a Psychosexual Follow - up in Young Adulthood
Guidelines of psychosexual management for infants born with physical intersex conditions
sex assignment should be to the gender that carries the best prognosis for good reproductive function, good sexual function, normal - looking external genitalia and physical appearance, and a stable gender identity
decision regarding sex assignment should be made as early as possible
there should be minimal uncertainty and ambiguity on the part of parents
J. Money used these guidelines in a case of a biologically normal male infant (one of a pair of monozygotic twins) whose penis was accidentally ablated during a circumcision at the age of 7 months. The decision to reassign the infant boy to the female sex and to rear him as a girl was made at 17 months, with surgical castration and initial genital reconstruction occurring at 21 months
the girl was described as having may tomboyish behavioral traits, a female gender identity had apparently differentiated. Thus, it was concluded that gender identity is sufficiently incompletely differentiated at birth as to permit successful assignment of a genetic male as a girl, in keeping with the experiences of rearing.
Subsequent follow - up by other investigators reported that by early adolescence the patient had rejected the female identity and began to live as a male at the age of 14 years. In adulthood, the patient recalled that he had never felt comfortable as a girl and his mother reported similar recollections. At age 25, the patient married a woman and adopted her children. The patient reported exclusive sexual attraction to females.
The present case report is a long - term psychosexual follow - up on a second case of ablatio penis in a 46,XY male. During an electrocautery circumcision at the age of 2 months, the patient sustained a burn of the skin of the entire penile shaft, and the penis eventually sloughed off. At age 7 months, the remainder of the penis and the testes were removed. By age 7 months, if not earlier, the decision was made to reassign the patient as a female and to raise the infant as a girl
At ages 16 and 26, the patient was living socially as a woman and denied any uncertainty about being a female
she was attracted predominantly to women in fantasy
she was in a relationship with a man and wished to be able to have intercourse. The patients self - described sexual identity was bisexual
"Intersex" - Frequently Asked Questions
Intersex Society of North America
What is intersexuality ( hermaphroditism )?
Our culture conceives sex anatomy as a dichotomy: humans come in two sexes
However, developmental embryology
Anatomic sex differentiation occurs on a male/female continuum
Genetic sex, or the organization of the sex chromosomes
However, something like 1/500 of the population have a karyotype other than XX or XY. Since genetic testing was instituted for women in the Olympic Games, a number of women have been disqualified as not women, after winning. However, none of the disqualified women is a man; all have atypical karyotypes
sex chromosomes determine the differentiation of the gonads into ovaries, testes, ovo - testes, or nonfunctioning streaks
What is androgen insensitivity syndrome?
Androgen Insensitivity Syndrome, or AIS, is a genetic condition, inherited (except for occasional spontaneous mutations), occurring in approximately 1 in 20,000 individuals
cells are unable to respond to androgen, or male hormones
Some individuals have partial androgen insensitivity
As in typical male fetuses, the MIH causes the fetal mullerian ducts to regress, so the fetus lacks uterus, fallopian tubes, and cervix plus upper part of vagina. However, because cells fail to respond to testosterone, the genitals differentiate in the female, rather than the male pattern, and Wolffian structures (epididymis, vas deferens, and seminal vesicles) are absent. The newborn AIS infant has genitals of normal female appearance, undescended or partially descended testes, and usually a short vagina with no cervix
At puberty, the estrogen produced by the testes produces breast growth
Vaginoplasty surgery is frequently performed on AIS infants or girls to increase the size of the vagina
Because AIS is a genetic defect located on the X chromosome, it runs in families
What is partial androgen insensitivity syndrome?
Extent of androgen insensitivity in 46 XY individuals is quite variable, even in a single family
typically results in ambiguous genitalia. The clitoris is large or, alternatively, the penis is small and hypospadic
What is Progestin Induced Virilization?
Caused by prenatal exposure to exogenous androgens, most commonly progestin
administered to prevent miscarriage in the 50s and 60s and it is converted to an androgen (virilizing hormone) by the prenatal XX persons metabolism. If the timing is right, the genitals are virilized with effects ranging from enlarged clitoris to the development of a complete phallus and the fusing of the labia
In other words, XX people affected in - utero by virilizing hormones can be born into a continuum of sex phenotype which ranges from female with larger clitoris to male with no testes
What is Adrenal Hyperplasia?
The most prevalent cause of intersexuality amongst XX people
about 1 in 20,000 births. It is caused when an anomaly of adrenal function (usually 21 - hydroxylase or 11 - hydroxylase deficiency) causes the synthesis
sex phenotype varies along the same continuum, with the possible added complication of metabolic problems which upset serum sodium balance
What is Klinefelter syndrome?
Most men inherit a single X chromosome from their mother, and a single Y chromosome from their father. Men with Klinefelter syndrome inherit an extra X chromosome from either father or mother; their karyotype is 47 XXY. Klinefelter is quite common, occurring in 1/500 to 1/1,000 male births. The effects of Klinefelter are quite variable
absence of sperm in the ejaculate, causing infertility. Except for small testes
dont virilize (develop facial and body hair, muscles, deep voice, larger penis and testes)
Physicians recommend that boys
be given testosterone at puberty
What is hypospadias?
Refers to a urethral meatus (pee - hole) which is located along the underside
Is there a risk of gonadal tumors?
Dysgenetic testicular tissue (testicular tissue that has developed in an unusual way) is at risk of developing tumors, and not merely because it is undescended. That is, the risk persists even after successful orchiopexy
Undescended testes in women with AIS are at risk of developing tumors
Testosterone replacement in men with dysgenetic testes may increase the probability of gonadal tumors developing
Tumors are not likely in the absence of a Y chromosome
Hormone replacement therapy and osteoporosis
Sex hormones (principally testosterone or estrogen) are necessary to maintain healthy adult bones
Where can I read some of the earliest first person writings of intersexuals?
Opinions of intersex specialists Grumbach of UCSF and Gearhart of Hopkins (surgery is necessary to prevent parents from treating child as an outcast) are contrasted with personal experience of Chase and Holmes (surgery experienced as mutilation, causing sexual dysfunction)
Once a dark secret, BMJ 1994; 308:542 (19 February)
A woman with XY karyotype and testicular feminization (androgen insensitivity syndrome) briefly relates how damaging she has found the secrecy surrounding her condition
David A. Hatch, M.D., 2003
If abnormalities of cell division occur a fetus with mosaicism may result. The baby may have both cells with 46 XY chromosomes and cells with 46 XX chromosomes. This condition is called hermaphroditism after the greek god Hermes and goddess Aphrodite. Because both male and female cells exist within the same fetus, both male and female structures develop. Typically, the penis is not completely virilized (hypospadias). One or both testes may not be palpable or they may be palpable, but undescended. Whenever you see an infant with both hypospadias and an undescended testis (cryptorchidism), you must consider the diagnosis of hermaphroditism
Whenever you suspect hermaphroditism you should confirm the diagnosis by ordering a karyotype. In addition, the child should have an abdominal ultrasound
MEDLINE plus, Health Information , October 11, 2007
Alternative names: hermaphrodite; intersexual; pseudohermaphroditism
A term referring to being of both sexes (intersexual)
True hermaphroditism requires the presence of both ovarian (female) and testicular (male) reproductive tissue and is relatively rare and poorly understood. Pseudohermaphroditism is more common and from a medical standpoint hermaphroditism suggests two factors:
- ambiguous external genitalia
- genitalia that may not match the genetic make-up of the person (example: female genitalia in an XY, genetically male, individual.)
The following conditions can produce ambiguous genitalia
- congenital adrenal hyperplasia
- fetal exposure to progestins (see progestins - oral) or androgens
- testicular feminization syndrome
- XY gonadal dysgenesis
- XY gonadal agenesis
- chromosomal abnormalities
- 4p syndrome
- 13q syndrome
HUMAN RIGHTS FOR INTERSEXUALS INTERSEX INDIVIDUALS DISPUTE WISDOM OF SURGERY ON INFANTS
Cheryl Chases clitoris was surgically removed when she was 18 months old
Initially doctors thought Chase should be reared as a boy, and she was named Charlie. But further consultation with different doctors led to the decision to raise her as a girl
Until I was 35, I was ashamed and terrified that people would find out that I was different than a woman. Like many, supposedly happy and successful patients, I was silenced.
she took the revolutionary step of founding the Intersex Society of North America (ISNA), a San Francisco based peer support and advocacy group. Initially just a loose association on the internet, ISNA now has 1,400 members, holds retreats for intersex people, has produced a video, lobbies, holds demonstrations, maintains a website, and puts intersex people in touch with each other throughout North America
when all causes of intersex are considered, as many as one in 2,000 babies are affected
Current medical treatment for intersex individuals is in a state of flux. Recently The Journal of Clinical Ethics devoted an entire issue to the subject, ultimately recommending major changes
Professor of Pediatric Endocrinology Melvin Grumbach
Speaking from an office cluttered with journals and papers on this subject in which he is a renowned expert, he cites the advantages of microsurgery, unavailable when Chases clitoris was removed. When I was a fellow at Hopkins, they were doing clitorectomy on girls with congenital adrenal hyperplasia (CAH)
When I was at Columbia, clitoral recessions were developed
were all sexually functional and happy
We dont see a difference between clitorectomy and clitoral recession [in which the bulk of the clitoris is reduced by removal of part of the erectile bodies of the clitoral shaft]. Kinsey showed that women masturbate by stimulating the shaft of the clitoris, not the glans. Recession removes the shaft.
Chase isnt surprised by Grumbachs and Baskins faith
They are always saying these new techniques are better, but there are no long - term outcome studies
Surgeons are not trained to deal with parents who are upset. They are trained to fix things
There is a principle in medicine - do no harm. They [surgeons] dont know what effect their drastic invasive, irreversible interventions are having
Endocrinologist Grumbach is skeptical of this viewpoint. If someone is telling you, you shouldnt modify the external genitalia, well, the parents wouldnt stand for it. They want it repaired!
acknowledges that it can be very disturbing to parents to give birth to an infant who is intersex.
It is very disturbing, agrees Chase. And when people are really disturbed, its not the time to make major, irreversible decisions. Instead, ISNA proposes that the parents receive counseling, and are put in contact with other parents of intersex children
The child will assert their gender identity between the ages of six and ten, notes Devore
The ethical issue most prominent in this debate is that of patient autonomy - the right of patients to decide for themselves what treatments they receive
Parents make decisions for their kids. Thats what parents do.
Chase was adamant that the surgery is being done for the psychological adjustment of the parents, which strikes her and other adult intersexes as horribly wrong. The infant is the patient, not the parents!
ISNA also takes issue with the criteria through which sex is assigned. In the case of congenital adrenal hyperplasia, the excuse for the surgery is that the girl who has a vagina created will be fertile as a woman. But if you had to choose between fertility and sexual function, which would you choose?
Baskin is horrified by this attitude. The majority of these patients
dont look like a girl
I am trying to help kids.
After all the debate and division
Everyone agrees that patients and parents need more psychosocial support
Grumbach believes that groups like ISNA have changed treatment in positive ways
Sensitivity has gone up a couple of logs
A good psychological social worker would be a tremendous help
get long - term psychiatry
provide support. That is one of the real deficiencies in care.
scoffs at the idea that trained counselors arent available. The parents need counseling. They need to be told that this [intersex] is a way a person can be, even though it is not what the parents expected
Genital mutilation in the name of normality is relatively new; older anatomical textbooks show many variations in genital structure among intersex individuals
If you personally enjoy sex at all
think about what it would be like to have had your genitals cut off when you were a baby for no other reason than that they were too large or too small
Mullerian inhibiting substance in the diagnosis and management of intersex and gonadal abnormalities
ML Gustafson et al., Journal of Pediatric Surgery, VOL. 28, NO. 3: pp.439-44
Mullerian inhibiting substance (MIS), a gonadal hormone important in sexual differentiation, is high (10 to 70 ng/ml) in human male serum postnatally for several years before declining during the peripubertal period, but is undetectable in female serum until the onset of puberty. The sexually dimorphic secretion of MIS suggested possibilities for its use in several clinical settings
Serum MIS levels correlated with the presence of testicular tissue
MIS may be a more sensitive marker for the presence of testicular tissue than serum testosterone levels
Intersex Society of North America
To end shame, secrecy, and unwanted genital surgeries for people born with atypical sex anatomy
Intersex - Hermaphroditism
I.B.I.S. Birth Defects, September 2, 2003
A fact sheet for specialists in Ukrainian
Definition ... Clinical symptoms ... Classification ... Role of hormones ... Consection of sexual development ... Diagnosis and differential diagnosis ... Sexual development charts ... Diagnostic algorithm ... Determination of child's sex ... Treatment ... Care: psychological peculiarities ... Prenatal diagnosis and prevention ...
Intersex - Hermaphroditism
I.B.I.S. Birth Defects, August 27, 2003
A fact sheet for parents in Ukrainian
What is intersex ... Why does it happen ... How can sex of a child be determined ... Treatment possibilities ... Care for children with intersex ...
Last Updated: 2023/04/03