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Wikipedia

Intersex

April 26, 2023

This article is about intersex in humans. For intersex in other animals, see Intersex (biology).
Not to be confused with Hermaphrodite.

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".[1][2]

Participants at the third International Intersex Forum, Malta, in December 2013

Sex assignment at birth usually aligns with a child's anatomical sex and phenotype. The number of births with ambiguous genitals is in the range of 1:4500–1:2000 (0.02%–0.05%).[3] Other conditions involve atypical chromosomes, gonads, or hormones.[4][5] Some persons may be assigned and raised as a girl or boy but then identify with another gender later in life, while most continue to identify with their assigned sex.[6][7][8] The number of births where the baby is intersex has been reported differently depending on who reports and which definition of intersex is used. Anne Fausto-Sterling and her co-authors suggest that the prevalence of "nondimorphic sexual development" might be as high as 1.7%.[9][10] A study published by Leonard Sax reports that this figure includes conditions such as Klinefelter syndrome (XXY) which most clinicians do not recognize as intersex, and that if the term is understood to mean only "conditions in which chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype is not classifiable as either male or female", the prevalence of intersex is about 0.018%.[4][11][12]

Terms used to describe intersex people are contested, and change over time and place. Intersex people were previously referred to as "hermaphrodites" or "congenital eunuchs".[13][14] In the 19th and 20th centuries, some medical experts devised new nomenclature in an attempt to classify the characteristics that they had observed, the first attempt to create a taxonomic classification system of intersex conditions. Intersex people were categorized as either having "true hermaphroditism", "female pseudohermaphroditism", or "male pseudohermaphroditism".[15] These terms are no longer used, and terms including the word "hermaphrodite" are considered to be misleading, stigmatizing, and scientifically specious in reference to humans.[16] In biology, the term "hermaphrodite" is used to describe an organism that can produce both male and female gametes.[17][18] Some people with intersex traits use the term "intersex", and some prefer other language.[19][20][page range too broad] In clinical settings, the term "disorders of sex development" (DSD) has been used since 2006,[21] a shift in language considered controversial since its introduction.[22][23][24]

Intersex people face stigmatization and discrimination from birth, or following the discovery of intersex traits at stages of development such as puberty. Intersex people may face infanticide, abandonment, and stigmatization from their families.[25][26][27] Globally, some intersex infants and children, such as those with ambiguous outer genitalia, are surgically or hormonally altered to create more socially acceptable sex characteristics. This is considered controversial, with no firm evidence of favorable outcomes.[28] Such treatments may involve sterilization. Adults, including elite female athletes, have also been subjects of such treatment.[29][30] Increasingly, these issues are considered human rights abuses, with statements from international[31][32] and national human rights and ethics institutions (see intersex human rights).[33][34] Intersex organizations have also issued statements about human rights violations, including the 2013 Malta declaration of the third International Intersex Forum.[35] In 2011, Christiane Völling became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention.[36] In April 2015, Malta became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people.[37][38]

Terminology

There is no clear consensus definition of intersex and no clear delineation of which specific conditions qualify an individual as intersex.[39] The World Health Organization's International Classification of Diseases (ICD), the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and many medical journals classify intersex traits or conditions among disorders of sex development (DSD).[40]

A common adjective for people with disorders of sex development (DSD) is "intersex".[1]

Etymology and definitions

In 1917, Richard Goldschmidt created the term "intersexuality" to refer to a variety of physical sex ambiguities.[15] However, according to The SAGE Encyclopedia of LGBTQ Studies, it was not until Anne Fausto Sterling published her article "The Five Sexes: Why Male and Female Are Not Enough" in 1993 that the term reached popularity.[41]

 
Model Hanne Gaby Odiele photographed by Ed Kavishe for Fashionwirepress. In 2017 Odiele disclosed having the intersex trait androgen insensitivity syndrome.

According to the UN Office of the High Commissioner for Human Rights:

Intersex people are born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies. Intersex is an umbrella term used to describe a wide range of natural bodily variations.[2]

Attitudes towards the term

Some intersex organizations reference "intersex people" and "intersex variations or traits"[42] while others use more medicalized language such as "people with intersex conditions",[43] or people "with intersex conditions or DSDs (differences of sex development)" and "children born with variations of sex anatomy".[44] In May 2016, interACT published a statement recognizing "increasing general understanding and acceptance of the term 'intersex'".[45]

Australian sociological research on 272 "people born with atypical sex characteristics", published in 2016, found that 60% of respondents used the term "intersex" to self-describe their sex characteristics, including people identifying themselves as intersex, describing themselves as having an intersex variation or, in smaller numbers, having an intersex condition. Respondents also commonly used diagnostic labels and referred to their sex chromosomes, with word choices depending on audience.[7][46]

Research on 202 respondents by the Lurie Children's Hospital, Chicago, and the AIS-DSD Support Group (now known as InterConnect Support Group)[47] published in 2017 found that 80% of Support Group respondents "strongly liked, liked or felt neutral about intersex" as a term, while caregivers were less supportive.[48] The hospital reported that the use of the term "disorders of sex development" may negatively affect care.[49]

Another study by a group of children's hospitals in the United States found that 53% of 133 parent and adolescent participants recruited at five clinics did not like the term "intersex".[50] Participants who were members of support groups were more likely to dislike the term.[50] A "dsd-LIFE" study in 2020 found that around 43% of 179 participants thought the term "intersex" was bad, 20% felt neutral about the term, while the rest thought the term was good.[51]

The term "hermaphrodite"

Main article: Hermaphrodite

Historically, the term "hermaphrodite" was used in law to refer to people whose sex was in doubt. The 12th-century Decretum Gratiani states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails" ("Hermafroditus an ad testamentum adhiberi possit, qualitas sexus incalescentis ostendit.").[52][53] Similarly, the 17th-century English jurist and judge Edward Coke (Lord Coke), wrote in his Institutes of the Lawes of England on laws of succession stating, "Every heire is either a male, a female, or an hermaphrodite, that is both male and female. And an hermaphrodite (which is also called Androgynus) shall be heire, either as male or female, according to that kind of sexe which doth prevaile."[54][55]

During the Victorian era, medical authors attempted to ascertain whether or not humans could be hermaphrodites, adopting a precise biological definition for the term,[56] and making distinctions between "male pseudohermaphrodite", "female pseudohermaphrodite" and especially "true hermaphrodite".[57] These terms, which reflected histology (microscopic appearance) of the gonads, are no longer used.[58][59][60] Until the mid-20th century, "hermaphrodite" was used synonymously with "intersex".[61] Medical terminology shifted in the early 21st century, not only due to concerns about language, but also a shift to understandings based on genetics.[citation needed] The term "hermaphrodite" is also controversial as it implies the existence of someone is fully male and fully female something which is impossible, however is a frequent fantasy by certain people who seek “hermaphrodite” sex partners, in the Intersex movement these people are called "wannafucks."[62] As such the term "hermaphrodite" is often seen as degrading and offensive, although many intersex activists use it as a direct form of self empowerment and critique such as in the ISNA's first newsletter "Hermaphrodites with Attitude."'[62]

The Intersex Society of North America has stated that hermaphrodites should not be confused with intersex people and that using "hermaphrodite" to refer to intersex individuals is considered to be stigmatizing and misleading.[63]

Prevalence

 
The standard treatment in cases of Androgen Insensitivity Syndrome and other intersex conditions was to lie to patients. This extract is from a book published in 1963.

Estimates of the number of people who are intersex vary, depending on which conditions are counted as intersex.[4] The now-defunct Intersex Society of North America stated that:

If you ask experts at medical centers how often a child is born so noticeably atypical in terms of genitalia that a specialist in sex differentiation is called in, the number comes out to about 1 in 1500 to 1 in 2000 births [0.07–0.05%]. But a lot more people than that are born with subtler forms of sex anatomy variations, some of which won't show up until later in life.[64]

Anne Fausto-Sterling and her co-authors broadly said in 2000 that "[a]dding the estimates of all known causes of nondimorphic sexual development suggests that approximately 1.7% of all live births do not conform to a Platonic ideal of absolute sex chromosome, gonadal, genital, and hormonal dimorphism";[10][9] these publications have been widely quoted by intersex activists.[65][66][67] Of the 1.7 percent, 1.5 percentage points (88% of those considered "nondimorphic sexual development" in this figure) consist of individuals with late onset congenital adrenal hyperplasia (LOCAH) which may be asymptomatic but can present after puberty and cause infertility.[68]

In response to Fausto-Sterling, Leonard Sax estimated that the prevalence of intersex was about 0.018% of the world's population,[4] after discounting several conditions including LOCAH, Klinefelter syndrome (47,XXY), Turner syndrome (45,X), the chromosomal variants of 47,XYY and 47,XXX, and vaginal agenesis. Sax reasons that in these conditions chromosomal sex is consistent with phenotypic sex and phenotype is classifiable as either male or female.[4]

In a 2003 letter to the editor, political scientist Carrie Hull analyzed the data used by Fausto-Sterling and said the estimated intersex rate should instead have been 0.37%, due to many errors.[69] In a response letter published simultaneously, Fausto-Sterling welcomed the additional analysis and said "I am not invested in a particular final estimate, only that there BE an estimate".[69] A 2018 review reported that the number of births with ambiguous genitals is in the range of 0.02% to 0.05%.[3]

Intersex Human Rights Australia says it maintains 1.7% as its preferred upper limit "despite its flaws", stating both that the estimate "encapsulates the entire population of people who are stigmatized – or risk stigmatization – due to innate sex characteristics," and that Sax's definitions exclude individuals who experience such stigma and who have helped to establish the intersex movement.[70]

The following summarizes prevalences of traits that have been called intersex:

Prevalences of various conditions that have been called intersex
Intersex condition Sex specificity Approximate prevalence
Late onset congenital adrenal hyperplasia (nonclassical forms) Female (males are generally asymptomatic)[71] One in 50–1,000 births (0.1–0.2% up to 1–2% depending on population)[72]
Hypospadias Male One in 200–10,000 male births (0.01%–0.5%), prevalence estimates vary considerably[73]
Klinefelter syndrome Male One in 500–1,000 male births (0.1–0.2%)[74]
Trisomy X Female One in 1,000 female births (0.10%)[75]
Turner syndrome Female One in 2,500 female births (0.04%)[76]
Müllerian agenesis (of vagina, i.e., MRKH Syndrome) Female One in 4,500 female births (0.022%)[77]
Vaginal atresia Female One in 5,000 female births (0.02%)[78]
45,X/46,XY mosaicism Male One in 6,666 births (0.015%)[79]
XYY syndrome Male One in 7,000 male births (0.0142%)[80]
Congenital adrenal hyperplasia (classical forms) None (but virilization of female infants)[72][68] One in 10,000–20,000 births (0.01–0.02%)[68]
XXYY syndrome Male One in 18,000–40,000 male births (0.0025%–0.0055%)[81]
XX male syndrome Male One in 20,000 male births (0.005%)[82]
True hermaphroditism None One in 20,000 births (0.005%)[83]
XY gonadal dysgenesis Phenotypic female[84] One in 80,000 births (0.0013%)[85]
Androgen insensitivity syndrome (complete and partial phenotypes) Genetic male[86] One in 99,000 births (0.001%)[87]
Idiopathic (no discernable medical cause) None One in 110,000 births (0.0009%)[88]
Iatrogenic (caused by medical treatment, e.g., progestogen administered to pregnant mother) None No estimate
5-alpha-reductase deficiency Male No estimate
Aromatase excess syndrome None No estimate
Anorchia Male No estimate
Persistent Müllerian duct syndrome Male No estimate

Prevalences of specific conditions can vary across regions. In the Dominican Republic, 5-alpha-reductase deficiency is not uncommon in the town of Las Salinas, resulting in social acceptance of the intersex trait.[89] Men with the trait are called "güevedoces" (Spanish for "eggs at twelve"). 12 out of 13 families had one or more male family members that carried the gene. The overall incidence for the town was 1 in every 90 males were carriers, with other males either non-carriers or non-affected carriers.[90]

History

Main articles: Intersex in history, Timeline of intersex history, and History of intersex surgery
 
Hermaphroditus in a wall painting from Herculaneum (first half of the 1st century AD)
 
A Chola statue depicting Ardhanarishvara, a Hermaphroditus form of Shiva.

From early history, societies have been aware of intersex people. Some of the earliest evidence is found in mythology: the Greek historian Diodorus Siculus wrote of the mythological Hermaphroditus in the first century BC, who was "born with a physical body which is a combination of that of a man and that of a woman", and reputedly possessed supernatural properties.[91] He also recounted the lives of Diophantus of Abae and Callon of Epidaurus.[92] Ardhanarishvara, an androgynous composite form of male deity Shiva and female deity Parvati, originated in Kushan culture as far back as the first century AD.[93] A statue depicting Ardhanarishvara is included in India's Meenakshi Temple; this statue clearly shows both male and female bodily elements.[94]

Hippocrates (c. 460 – c. 370 BC Greek physician) and Galen (129 – c. 200/216 AD Roman physician, surgeon and philosopher) both viewed sex as a spectrum between men and women, with "many shades in between, including hermaphrodites, a perfect balance of male and female".[95] Pliny the Elder (AD 23/24–79) the Roman naturalist described "those who are born of both sexes, whom we call hermaphrodites, at one time androgyni" (from the Greek andr-, "man," and gyn-, "woman").[96] Augustine (354 – 28 August 430 AD) the influential Catholic theologian wrote in The Literal Meaning of Genesis that humans were created in two sexes, despite "as happens in some births, in the case of what we call androgynes".[95]

In medieval and early modern 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.[97] The 12th century Decretum Gratiani states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails".[98][99][100] The foundation of common law, the 17th 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."[101][55] Legal cases have been described in canon law and elsewhere over the centuries.

Some non-European societies have sex or gender systems that recognize more than the two categories of male/man and female/woman. Some of these cultures, for instance the South-Asian Hijra communities, may include intersex people in a third gender category.[102][103] Although–according to Morgan Holmes–early Western anthropologists categorized such cultures "primitive," Holmes has argued that analyses of these cultures have been simplistic or romanticized and fail to take account of the ways that subjects of all categories are treated.[104]

During the Victorian era, medical authors introduced the terms "true hermaphrodite" for an individual who has both ovarian and testicular tissue, "male pseudo-hermaphrodite" for a person with testicular tissue, but either female or ambiguous sexual anatomy, and "female pseudo-hermaphrodite" for a person with ovarian tissue, but either male or ambiguous sexual anatomy. Some later shifts in terminology have reflected advances in genetics, while other shifts are suggested to be due to pejorative associations.[105]

The term "intersexuality" was coined by Richard Goldschmidt in 1917.[106] The first suggestion to replace the term "hermaphrodite" with "intersex" was made by Cawadias in the 1940s.[61]

Since the rise of modern medical science, some intersex people with ambiguous external genitalia have had their genitalia surgically modified to resemble either female or male genitals. Surgeons pinpointed intersex babies as a "social emergency" when born.[107] An 'optimal gender policy', initially developed by John Money, stated that early intervention helped avoid gender identity confusion, but this lacks evidence.[108] Early interventions have adverse consequences for psychological and physical health.[34] Since advances in surgery have made it possible for intersex conditions to be concealed, many people are not aware of how frequently intersex conditions arise in human beings or that they occur at all.[109]

Dialogue between what were once antagonistic groups of activists and clinicians has led to only slight changes in medical policies and how intersex patients and their families are treated in some locations.[110] In 2011, Christiane Völling became the first intersex person known to have successfully sued for damages in a case brought for non-consensual surgical intervention.[36] In April 2015, Malta became the first country to outlaw non-consensual medical interventions to modify sex anatomy, including that of intersex people.[37] Many civil society organizations and human rights institutions now call for an end to unnecessary "normalizing" interventions, including in the Malta declaration.[111][1]

Human rights and legal issues

 
Intersex activists on a boat at Utrecht Canal Pride in the Netherlands on June 16, 2018
Further information: Intersex rights by country

Human rights institutions are placing increasing scrutiny on harmful practices and issues of discrimination against intersex people. These issues have been addressed by a rapidly increasing number of international institutions including, in 2015, the Council of Europe, the United Nations Office of the United Nations High Commissioner for Human Rights and the World Health Organization (WHO). These developments have been accompanied by International Intersex Forums and increased cooperation amongst civil society organizations. However, the implementation, codification, and enforcement of intersex human rights in national legal systems remains slow.

Physical integrity and bodily autonomy

 
  Legal prohibition of non-consensual medical interventions
  Regulatory suspension of non-consensual medical interventions
Main articles: Intersex human rights and Intersex medical interventions

Stigmatization and discrimination from birth may include infanticide, abandonment, and the stigmatization of families. The birth of an intersex child was often viewed as a curse or a sign of a witch mother, especially in parts of Africa.[25][26] Abandonments and infanticides have been reported in Uganda,[25] Kenya,[112] South Asia,[113] and China.[27]

Infants, children and adolescents also experience "normalising" interventions on intersex persons that are medically unnecessary and the pathologisation of variations in sex characteristics. In countries where the human rights of intersex people have been studied, medical interventions to modify the sex characteristics of intersex people have still taken place without the consent of the intersex person.[114][115] Interventions have been described by human rights defenders as a violation of many rights, including (but not limited to) bodily integrity, non-discrimination, privacy, and experimentation.[116] These interventions have frequently been performed with the consent of the intersex person's parents, when the person is legally too young to consent. Such interventions have been criticized by the WHO, other UN bodies such as the Office of the High Commissioner for Human Rights, and an increasing number of regional and national institutions due to their adverse consequences, including trauma, impact on sexual function and sensation, and violation of rights to physical and mental integrity.[1] The UN organizations decided that infant intervention should not be allowed, in favor of waiting for the child to mature enough to be a part of the decision-making – this allows for a decision to be made with total consent.[117] In April 2015, Malta became the first country to outlaw surgical intervention without consent.[37][38] In the same year, the Council of Europe became the first institution to state that intersex people have the right not to undergo sex affirmation interventions.[65]

Anti-discrimination and equal treatment

 
  Explicit protection on grounds of sex characteristics
  Explicit protection on grounds of intersex status
  Explicit protection on grounds of intersex within attribute of sex
Main article: Discrimination against intersex people

People born with intersex bodies are seen as different. Intersex infants, children, adolescents and adults "are often stigmatized and subjected to multiple human rights violations", including discrimination in education, healthcare, employment, sport, and public services.[2] Several countries have so far explicitly protected intersex people from discrimination, with landmarks including South Africa,[118] Australia,[119][120] and, most comprehensively, Malta.[121][122][123]

Remedies and claims for compensation

Main article: Intersex human rights

Claims for compensation and remedies for human rights abuses include the 2011 case of Christiane Völling in Germany.[36][124] A second case was adjudicated in Chile in 2012, involving a child and his parents.[125][126] A further successful case in Germany, taken by Michaela Raab, was reported in 2015.[127] In the United States, the Minor Child (M.C. v Aaronson) lawsuit was "a medical malpractice case related to the informed consent for a surgery performed on the Crawford's adopted child (known as M.C.) at [Medical University of South Carolina] in April 2006".[128] The case was one of the first lawsuit of its kind to challenge "legal, ethical, and medical issues regarding genital-normalizing surgery" in minors, and was eventually settled out of court by the Medical University of South Carolina for $440,000 in 2017.[129]

Information and support

Main article: Intersex human rights

Access to information, medical records, peer and other counselling and support. With the rise of modern medical science in Western societies, a secrecy-based model was also adopted, in the belief that this was necessary to ensure normal physical and psychosocial development.[130][131][132]

Legal recognition

Main article: Legal recognition of intersex people

The Asia Pacific Forum of National Human Rights Institutions states that legal recognition is firstly "about intersex people who have been issued a male or a female birth certificate being able to enjoy the same legal rights as other men and women."[35] In some regions, obtaining any form of birth certification may be an issue. A Kenyan court case in 2014 established the right of an intersex boy, "Baby A", to a birth certificate.[133]

Like all individuals, some intersex individuals may be raised as a certain sex (male or female) but then identify with another later in life, while most do not.[134][6][135][136] Recognition of third sex or gender classifications occurs in several countries,[137][138][139][140] However, it is controversial when it becomes assumed or coercive, as is the case with some German infants.[141][142] Sociological research in Australia, a country with a third 'X' sex classification, shows that 19% of people born with atypical sex characteristics selected an "X" or "other" option, while 75% of survey respondents self-described as male or female (52% as women, 23% as men), and 6% as unsure.[7][46]

LGBT and LGBTI

 
U.S. intersex activist Pidgeon Pagonis
Main article: Intersex and LGBT
 
ILGA conference 2018, group photo to mark Intersex Awareness Day

Intersex conditions can be contrasted with transgender gender identities and the attached gender dysphoria a transgender person may feel, wherein their gender identity does not match their assigned sex.[143][144][145] However, some people are both intersex and transgender; though intersex people by definition have variable sex characteristics that do not align with either typically male or female, this may be considered separate to an individual's assigned gender, the way they are raised and perceived, and their internal gender identity.[146] A 2012 clinical review paper found that between 8.5% and 20% of people with intersex variations experienced gender dysphoria.[135] In an analysis of the use of preimplantation genetic diagnosis to eliminate intersex traits, Behrmann and Ravitsky state: "Parental choice against intersex may ... conceal biases against same-sex attractedness and gender nonconformity."[147]

The relationship of intersex people and communities to LGBTQ communities is complex,[148] but intersex people are often added to the LGBT acronym, resulting in the acronym LGBTI. Emi Koyama describes how inclusion of intersex in LGBTI can fail to address intersex-specific human rights issues, including creating false impressions "that intersex people's rights are protected" by laws protecting LGBT people, and failing to acknowledge that many intersex people are not LGBT.[149] Organisation Intersex International Australia states that some intersex individuals are homosexual, and some are heterosexual, but "LGBTI activism has fought for the rights of people who fall outside of expected binary sex and gender norms."[150][151] Julius Kaggwa of SIPD Uganda has written that, while the gay community "offers us a place of relative safety, it is also oblivious to our specific needs".[152] Mauro Cabral has written that transgender people and organizations "need to stop approaching intersex issues as if they were trans issues", including use of intersex conditions and people as a means of explaining being transgender; "we can collaborate a lot with the intersex movement by making it clear how wrong that approach is".[153]

In society

Fiction, literature and media

Main articles: Literature about intersex and Intersex characters in fiction
 
Kristi Bruce after shooting the documentary XXXY, 2000

An intersex character is the narrator in Jeffrey Eugenides' Pulitzer Prize-winning novel Middlesex.

The memoir, Born Both: An Intersex Life (Hachette Books, 2017), by intersex author and activist Hida Viloria, received strong praise from The New York Times Book Review, The Washington Post, Rolling Stone, People Magazine, and Psychology Today, was one of School Library Journal's 2017 Top Ten Adult Books for Teens, and was a 2018 Lambda Literary Award nominee.

Television works about intersex and films about intersex are scarce. The Spanish-language film XXY won the Critics' Week grand prize at the 2007 Cannes Film Festival and the ACID/CCAS Support Award.[154] Faking It is notable for providing both the first intersex main character in a television show,[155] and television's first intersex character played by an intersex actor.[156]

Civil society institutions

Main article: Intersex civil society organizations

Intersex peer support and advocacy organizations have existed since at least 1985, with the establishment of the Androgen Insensitivity Syndrome Support Group Australia in 1985.[157] The Androgen Insensitivity Syndrome Support Group (UK) was established in 1988.[158] The Intersex Society of North America (ISNA) may have been one of the first intersex civil society organizations to have been open to people regardless of diagnosis; it was active from 1993 to 2008.[159]

Events

Main articles: Intersex Awareness Day and Intersex Day of Remembrance

Intersex Awareness Day is an internationally observed civil awareness day designed to highlight the challenges faced by intersex people, occurring annually on 26 October. It marks the first public demonstration by intersex people, which took place in Boston on 26 October 1996, outside a venue where the American Academy of Pediatrics was holding its annual conference.[160]

Intersex Day of Remembrance, also known as Intersex Solidarity Day, is an internationally observed civil awareness day designed to highlight issues faced by intersex people, occurring annually on 8 November. It marks the birthday of Herculine Barbin, a French intersex person whose memoirs were later published by Michel Foucault in Herculine Barbin: Being the Recently Discovered Memoirs of a Nineteenth-century French Hermaphrodite.

Flag

Main article: Intersex flag
 
Intersex flag

The intersex flag was created in July 2013 by Morgan Carpenter of Intersex Human Rights Australia to create a flag "that is not derivative, but is yet firmly grounded in meaning". The circle is described as "unbroken and unornamented, symbolising wholeness and completeness, and our potentialities. We are still fighting for bodily autonomy and genital integrity, and this symbolises the right to be who and how we want to be."[161]

Religion

Main article: Intersex people and religion

In Judaism, the Talmud contains extensive discussion concerning the status of two types of intersex people in Jewish law; namely, the androgynous, who exhibit both male and female external sexual organs, and the tumtum, who exhibit neither. In the 1970s and 1980s, the treatment of intersex babies started to be discussed in Orthodox Jewish medical halacha by prominent rabbinic leaders, such as Eliezer Waldenberg and Moshe Feinstein.[162]

Sport

Main article: Sex verification in sports

Erik Schinegger, Foekje Dillema, Maria José Martínez-Patiño and Santhi Soundarajan were subject to adverse sex verification testing resulting in ineligibility to compete in organised competitive competition. Stanisława Walasiewicz was posthumously ruled ineligible to have competed.[163]

The South African middle-distance runner Caster Semenya won gold at the World Championships in the women's 800 metres and won silver in the 2012 Summer Olympics. When Semenya won gold in the World Championships, the International Association of Athletics Federations (IAAF) requested sex verification tests. The results were not released. Semenya was ruled eligible to compete.[164]

Katrina Karkazis, Rebecca Jordan-Young, Georgiann Davis and Silvia Camporesi have claimed that IAAF policies on "hyperandrogenism" in female athletes are "significantly flawed", arguing that the policy does not protect against breaches of privacy, requires athletes to undergo unnecessary treatment in order to compete, and intensifies "gender policing", and recommended that athletes be able to compete in accordance with their legally-recognised gender.[165]

In April 2014, the BMJ reported that four elite women athletes with XY chromosomes and 5-ARD were subjected to sterilization and "partial clitoridectomies" in order to compete in sport. The authors noted that partial clitoridectomy was "not medically indicated" and "does not relate to real or perceived athletic 'advantage'."[29] Intersex advocates[who?] regarded this intervention as "a clearly coercive process".[166] In 2016, the United Nations Special Rapporteur on health, Dainius Pūras, criticized "current and historic" sex verification policies, describing how "a number of athletes have undergone gonadectomy (removal of reproductive organs) and partial clitoridectomy (a form of female genital mutilation) in the absence of symptoms or health issues warranting those procedures."[167]

Biology

Main article: Intersex (biology)

The notion of intersex individuals can be understood in the context of sexual system biology that varies across different types of organisms. Most animal species (~95%, including humans) are gonochoric, in which individuals are of either a female or male sex.[168] Hermaphroditic species (some animals and most flowering plants[169]) are represented by individuals that can express both sexes simultaneously or sequentially during their lifetimes.[170] Intersex individuals in a number of gonochoric species, who express both female and male phenotypic characters to some degree,[171] are known to exist at very low prevalences.

Although "hermaphrodite" and "intersex" have been used synonymously in humans,[172][pages needed] a hermaphrodite is specifically an individual capable of producing female and male gametes.[173] While there are reports of individuals that seemed to have the potential to produce both types of gamete,[174] in more recent years the term hermaphrodite as applied to humans has fallen out of favor, since female and male reproductive functions have not been observed together in the same individual.[175]

Medical

Research in the late 20th century led to a growing medical consensus that diverse intersex bodies are normal, but relatively rare, forms of human biology.[6][176][177][178] Clinician and researcher Milton Diamond stresses the importance of care in the selection of language related to intersex people:

Foremost, we advocate use of the terms "typical", "usual", or "most frequent" where it is more common to use the term "normal." When possible avoid expressions like maldeveloped or undeveloped, errors of development, defective genitals, abnormal, or mistakes of nature. Emphasize that all of these conditions are biologically understandable while they are statistically uncommon.[179]

Medical classifications

Sexual differentiation

Main article: Sexual differentiation

The common pathway of sexual differentiation, where a productive human female has an XX chromosome pair, and a productive male has an XY pair, is relevant to the development of intersex conditions.

During fertilization, the sperm adds either an X (female) or a Y (male) chromosome to the X in the ovum. This determines the genetic sex of the embryo. During the first weeks of development, genetic male and female fetuses are "anatomically indistinguishable", with primitive gonads beginning to develop during approximately the sixth week of gestation. The gonads, in a bipotential state, may develop into either testes (the male gonads) or ovaries (the female gonads), depending on the consequent events.[180] Up until and including the seventh week, genetically female and genetically male fetuses appear identical.

At around eight weeks of gestation, the gonads of an XY embryo differentiate into functional testes, secreting testosterone. Ovarian differentiation, for XX embryos, does not occur until approximately week 12 of gestation. In typical female differentiation, the Müllerian duct system develops into the uterus, Fallopian tubes, and inner third of the vagina. In males, the Müllerian duct-inhibiting hormone MIH causes this duct system to regress. Next, androgens cause the development of the Wolffian duct system, which develops into the vas deferens, seminal vesicles, and ejaculatory ducts.[180] By birth, the typical fetus has been completely sexed male or female, meaning that the genetic sex (XY-male or XX-female) corresponds with the phenotypical sex; that is to say, genetic sex corresponds with internal and external gonads, and external appearance of the genitals.

Signs

There are a variety of symptoms that can occur. Ambiguous genitalia is the most common sign. There can be micropenis, clitoromegaly, partial labial fusion, electrolyte abnormalities, delayed or absent puberty, unexpected changes at puberty, hypospadias, labial or inguinal (groin) masses (which may turn out to be testes) in girls and undescended testes (which may turn out to be ovaries) in boys.[181]

Ambiguous genitalia

Ambiguous genitalia may appear as a large clitoris or as a small penis.

 
The Quigley scale is a method for describing genital development in AIS.

Because there is variation in all of the processes of the development of the sex organs, a child can be born with a sexual anatomy that is typically female or feminine in appearance with a larger-than-average clitoris (clitoral hypertrophy) or typically male or masculine in appearance with a smaller-than-average penis that is open along the underside. The appearance may be quite ambiguous, describable as female genitals with a very large clitoris and partially fused labia, or as male genitals with a very small penis, completely open along the midline ("hypospadic"), and empty scrotum. Fertility is variable.[citation needed]

Measurement systems for ambiguous genitalia

The orchidometer is a medical instrument to measure the volume of the testicles. It was developed by Swiss pediatric endocrinologist Andrea Prader. The Prader scale[182] and Quigley scale are visual rating systems that measure genital appearance. These measurement systems were satirized in the Phall-O-Meter, created by the (now defunct) Intersex Society of North America.[183][184][185]

Other signs

In order to help in classification, methods other than a genitalia inspection can be performed. For instance, a karyotype display of a tissue sample may determine which of the causes of intersex is prevalent in the case. Additionally, electrolyte tests, endoscopic exam, ultrasound and hormone stimulation tests can be done.[186]

Causes

Intersex can be divided into four categories which are: 46, XX intersex; 46, XY intersex; true gonadal intersex; and complex or undetermined intersex.[181]

46, XX intersex

This condition used to be called "female pseudohermaphroditism". Persons with this condition have female internal genitalia and karyotype (XX) and various degree of external genitalia virilization.[187] External genitalia is masculinized congenitally when female fetus is exposed to excess androgenic environment.[181] Hence, the chromosome of the person is of a woman, the ovaries of a woman, but external genitals that appear like a male. The labia fuse, and the clitoris enlarges to appear like a penis. The causes of this can be male hormones taken during pregnancy, congenital adrenal hyperplasia, male-hormone-producing tumors in the mother and aromatase deficiency.[181]

46, XY intersex

This condition used to be called "male pseudohermaphroditism". This is defined as incomplete masculinization of the external genitalia.[188] Thus, the person has male chromosomes, but the external genitals are incompletely formed, ambiguous, or clearly female.[181][189] This condition is also called 46, XY with undervirilization.[181] 46, XY intersex has many possible causes, which can be problems with the testes and testosterone formation.[181] Also, there can be problems with using testosterone. Some people lack the enzyme needed to convert testosterone to dihydrotestosterone, which is a cause of 5-alpha-reductase deficiency.[181] Androgen insensitivity syndrome is the most common cause of 46, XY intersex.[181]

True gonadal intersex

This condition used to be called "true hermaphroditism". This is defined as having asymmetrical gonads with ovarian and testicular differentiation on either sides separately or combined as ovotestis.[190] In most cases, the cause of this condition is unknown.

Complex or undetermined intersex

This is the condition of having any chromosome configurations rather than 46, XX or 46, XY intersex. This condition does not result in an imbalance between internal and external genitalia. However, there may be problems with sex hormone levels, overall sexual development, and altered numbers of sex chromosomes.[181]

Conditions

Further information: Disorders of sex development

There are a variety of opinions on what conditions or traits are and are not intersex, dependent on the definition of intersex that is used. Current human rights based definitions stress a broad diversity of sex characteristics that differ from expectations for male or female bodies.[2] During 2015, the Council of Europe,[65] the European Union Agency for Fundamental Rights[191] and Inter-American Commission on Human Rights[192] have called for a review of medical classifications on the basis that they presently impede enjoyment of the right to health; the Council of Europe expressed concern that "the gap between the expectations of human rights organisations of intersex people and the development of medical classifications has possibly widened over the past decade".[65][191][192]

Medical interventions

 
Hong Kong intersex activist Small Luk
Main article: Intersex medical interventions
Further information: History of intersex surgery

Rationales

Medical interventions take place to address physical health concerns and psychosocial risks. Both types of rationale are the subject of debate, particularly as the consequences of surgical (and many hormonal) interventions are lifelong and irreversible. Questions regarding physical health include accurately assessing risk levels, necessity, and timing. Psychosocial rationales are particularly susceptible to questions of necessity as they reflect social and cultural concerns.

There remains no clinical consensus about an evidence base, surgical timing, necessity, type of surgical intervention, and degree of difference warranting intervention.[193][194][195] Such surgeries are the subject of significant contention due to consequences that include trauma, impact on sexual function and sensation, and violation of rights to physical and mental integrity.[1] This includes community activism,[105] and multiple reports by international human rights[31][65][35][196] and health[132] institutions and national ethics bodies.[34][197]

In the cases where gonads may pose a cancer risk, as in some cases of androgen insensitivity syndrome,[198] concern has been expressed that treatment rationales and decision-making regarding cancer risk may encapsulate decisions around a desire for surgical "normalization".[33]

Types

  • Feminizing and masculinizing surgeries: Surgical procedures depend on the diagnosis, and there is often a concern as to whether surgery should be performed at all. Typically, surgery is performed shortly after birth. Defenders of the practice argue that individuals must be clearly identified as male or female for them to function socially and develop "normally". Psychosocial reasons are often stated.[21] This is criticised by many human rights institutions, and authors. Unlike other aesthetic surgical procedures performed on infants, such as corrective surgery for a cleft lip, genital surgery may lead to negative consequences for sexual functioning in later life, or feelings of freakishness and unacceptability.[199]
  • Hormone treatment: There is widespread evidence of prenatal testing and hormone treatment to prevent or eliminate intersex traits,[200] associated also with the problematization of sexual orientation and gender non-conformity.[200][201]
  • Psychosocial support: All stakeholders support psychosocial support. A joint international statement by participants at the Third International Intersex Forum in 2013 sought, amongst other demands: "Recognition that medicalization and stigmatisation of intersex people result in significant trauma and mental health concerns. In view of ensuring the bodily integrity and well-being of intersex people, autonomous non-pathologising psycho-social and peer support be available to intersex people throughout their life (as self-required), as well as to parents and/or care providers."[This quote needs a citation]
  • Genetic selection and terminations: The ethics of preimplantation genetic diagnosis to select against intersex traits was the subject of 11 papers in the October 2013 issue of the American Journal of Bioethics.[202] There is widespread evidence of pregnancy terminations arising from prenatal testing, as well as prenatal hormone treatment to prevent intersex traits. Behrmann and Ravitsky find social concepts of sex, gender and sexual orientation to be "intertwined on many levels. Parental choice against intersex may thus conceal biases against same-sex attractedness and gender nonconformity."[147]
  • Medical display. Photographs of intersex children's genitalia are circulated in medical communities for documentary purposes, and individuals with intersex traits may be subjected to repeated genital examinations and display to medical teams. Problems associated with experiences of medical photography of intersex children have been discussed[203] along with their ethics, control and usage.[204][205] "The experience of being photographed has exemplified for many people with intersex conditions the powerlessness and humiliation felt during medical investigations and interventions".[204]
  • Gender dysphoria: The DSM-5 included a change from using gender identity disorder to gender dysphoria. This revised code now specifically includes intersex people who do not identify with their sex assigned at birth and experience clinically significant distress or impairment, using the language of disorders of sex development.[206]

See also

References

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Bibliography

Further information: Intersex human rights reports

External links

  Media related to Intersex at Wikimedia Commons

External video
  " What It's Like To Be Intersex", Lizz Warner, BuzzFeed

April 26, 2023
intersex, this, article, about, intersex, humans, intersex, other, animals, biology, confused, with, hermaphrodite, people, individuals, born, with, several, characteristics, including, chromosome, patterns, gonads, genitals, that, according, office, united, n. This article is about intersex in humans For intersex in other animals see Intersex biology Not to be confused with Hermaphrodite 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 1 2 Participants at the third International Intersex Forum Malta in December 2013 Sex assignment at birth usually aligns with a child s anatomical sex and phenotype The number of births with ambiguous genitals is in the range of 1 4500 1 2000 0 02 0 05 3 Other conditions involve atypical chromosomes gonads or hormones 4 5 Some persons may be assigned and raised as a girl or boy but then identify with another gender later in life while most continue to identify with their assigned sex 6 7 8 The number of births where the baby is intersex has been reported differently depending on who reports and which definition of intersex is used Anne Fausto Sterling and her co authors suggest that the prevalence of nondimorphic sexual development might be as high as 1 7 9 10 A study published by Leonard Sax reports that this figure includes conditions such as Klinefelter syndrome XXY which most clinicians do not recognize as intersex and that if the term is understood to mean only conditions in which chromosomal sex is inconsistent with phenotypic sex or in which the phenotype is not classifiable as either male or female the prevalence of intersex is about 0 018 4 11 12 Terms used to describe intersex people are contested and change over time and place Intersex people were previously referred to as hermaphrodites or congenital eunuchs 13 14 In the 19th and 20th centuries some medical experts devised new nomenclature in an attempt to classify the characteristics that they had observed the first attempt to create a taxonomic classification system of intersex conditions Intersex people were categorized as either having true hermaphroditism female pseudohermaphroditism or male pseudohermaphroditism 15 These terms are no longer used and terms including the word hermaphrodite are considered to be misleading stigmatizing and scientifically specious in reference to humans 16 In biology the term hermaphrodite is used to describe an organism that can produce both male and female gametes 17 18 Some people with intersex traits use the term intersex and some prefer other language 19 20 page range too broad In clinical settings the term disorders of sex development DSD has been used since 2006 21 a shift in language considered controversial since its introduction 22 23 24 Intersex people face stigmatization and discrimination from birth or following the discovery of intersex traits at stages of development such as puberty Intersex people may face infanticide abandonment and stigmatization from their families 25 26 27 Globally some intersex infants and children such as those with ambiguous outer genitalia are surgically or hormonally altered to create more socially acceptable sex characteristics This is considered controversial with no firm evidence of favorable outcomes 28 Such treatments may involve sterilization Adults including elite female athletes have also been subjects of such treatment 29 30 Increasingly these issues are considered human rights abuses with statements from international 31 32 and national human rights and ethics institutions see intersex human rights 33 34 Intersex organizations have also issued statements about human rights violations including the 2013 Malta declaration of the third International Intersex Forum 35 In 2011 Christiane Volling became the first intersex person known to have successfully sued for damages in a case brought for non consensual surgical intervention 36 In April 2015 Malta became the first country to outlaw non consensual medical interventions to modify sex anatomy including that of intersex people 37 38 Contents 1 Terminology 1 1 Etymology and definitions 1 2 Attitudes towards the term 1 3 The term hermaphrodite 2 Prevalence 3 History 4 Human rights and legal issues 4 1 Physical integrity and bodily autonomy 4 2 Anti discrimination and equal treatment 4 3 Remedies and claims for compensation 4 4 Information and support 4 5 Legal recognition 5 LGBT and LGBTI 6 In society 6 1 Fiction literature and media 6 2 Civil society institutions 6 3 Events 6 4 Flag 6 5 Religion 6 6 Sport 7 Biology 8 Medical 8 1 Medical classifications 8 1 1 Sexual differentiation 8 1 2 Signs 8 1 3 Ambiguous genitalia 8 1 4 Measurement systems for ambiguous genitalia 8 1 5 Other signs 8 1 6 Causes 8 1 6 1 46 XX intersex 8 1 6 2 46 XY intersex 8 1 6 3 True gonadal intersex 8 1 6 4 Complex or undetermined intersex 8 1 7 Conditions 8 2 Medical interventions 8 2 1 Rationales 8 2 2 Types 9 See also 10 References 11 Bibliography 12 External linksTerminology EditThere is no clear consensus definition of intersex and no clear delineation of which specific conditions qualify an individual as intersex 39 The World Health Organization s International Classification of Diseases ICD the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders DSM and many medical journals classify intersex traits or conditions among disorders of sex development DSD 40 A common adjective for people with disorders of sex development DSD is intersex 1 Etymology and definitions Edit In 1917 Richard Goldschmidt created the term intersexuality to refer to a variety of physical sex ambiguities 15 However according to The SAGE Encyclopedia of LGBTQ Studies it was not until Anne Fausto Sterling published her article The Five Sexes Why Male and Female Are Not Enough in 1993 that the term reached popularity 41 Model Hanne Gaby Odiele photographed by Ed Kavishe for Fashionwirepress In 2017 Odiele disclosed having the intersex trait androgen insensitivity syndrome According to the UN Office of the High Commissioner for Human Rights Intersex people are born with sex characteristics including genitals gonads and chromosome patterns that do not fit typical binary notions of male or female bodies Intersex is an umbrella term used to describe a wide range of natural bodily variations 2 Attitudes towards the term Edit Some intersex organizations reference intersex people and intersex variations or traits 42 while others use more medicalized language such as people with intersex conditions 43 or people with intersex conditions or DSDs differences of sex development and children born with variations of sex anatomy 44 In May 2016 interACT published a statement recognizing increasing general understanding and acceptance of the term intersex 45 Australian sociological research on 272 people born with atypical sex characteristics published in 2016 found that 60 of respondents used the term intersex to self describe their sex characteristics including people identifying themselves as intersex describing themselves as having an intersex variation or in smaller numbers having an intersex condition Respondents also commonly used diagnostic labels and referred to their sex chromosomes with word choices depending on audience 7 46 Research on 202 respondents by the Lurie Children s Hospital Chicago and the AIS DSD Support Group now known as InterConnect Support Group 47 published in 2017 found that 80 of Support Group respondents strongly liked liked or felt neutral about intersex as a term while caregivers were less supportive 48 The hospital reported that the use of the term disorders of sex development may negatively affect care 49 Another study by a group of children s hospitals in the United States found that 53 of 133 parent and adolescent participants recruited at five clinics did not like the term intersex 50 Participants who were members of support groups were more likely to dislike the term 50 A dsd LIFE study in 2020 found that around 43 of 179 participants thought the term intersex was bad 20 felt neutral about the term while the rest thought the term was good 51 The term hermaphrodite Edit Main article Hermaphrodite Historically the term hermaphrodite was used in law to refer to people whose sex was in doubt The 12th century Decretum Gratiani states that Whether an hermaphrodite may witness a testament depends on which sex prevails Hermafroditus an ad testamentum adhiberi possit qualitas sexus incalescentis ostendit 52 53 Similarly the 17th century English jurist and judge Edward Coke Lord Coke wrote in his Institutes of the Lawes of England on laws of succession stating Every heire is either a male a female or an hermaphrodite that is both male and female And an hermaphrodite which is also called Androgynus shall be heire either as male or female according to that kind of sexe which doth prevaile 54 55 During the Victorian era medical authors attempted to ascertain whether or not humans could be hermaphrodites adopting a precise biological definition for the term 56 and making distinctions between male pseudohermaphrodite female pseudohermaphrodite and especially true hermaphrodite 57 These terms which reflected histology microscopic appearance of the gonads are no longer used 58 59 60 Until the mid 20th century hermaphrodite was used synonymously with intersex 61 Medical terminology shifted in the early 21st century not only due to concerns about language but also a shift to understandings based on genetics citation needed The term hermaphrodite is also controversial as it implies the existence of someone is fully male and fully female something which is impossible however is a frequent fantasy by certain people who seek hermaphrodite sex partners in the Intersex movement these people are called wannafucks 62 As such the term hermaphrodite is often seen as degrading and offensive although many intersex activists use it as a direct form of self empowerment and critique such as in the ISNA s first newsletter Hermaphrodites with Attitude 62 The Intersex Society of North America has stated that hermaphrodites should not be confused with intersex people and that using hermaphrodite to refer to intersex individuals is considered to be stigmatizing and misleading 63 Prevalence Edit The standard treatment in cases of Androgen Insensitivity Syndrome and other intersex conditions was to lie to patients This extract is from a book published in 1963 Estimates of the number of people who are intersex vary depending on which conditions are counted as intersex 4 The now defunct Intersex Society of North America stated that If you ask experts at medical centers how often a child is born so noticeably atypical in terms of genitalia that a specialist in sex differentiation is called in the number comes out to about 1 in 1500 to 1 in 2000 births 0 07 0 05 But a lot more people than that are born with subtler forms of sex anatomy variations some of which won t show up until later in life 64 Anne Fausto Sterling and her co authors broadly said in 2000 that a dding the estimates of all known causes of nondimorphic sexual development suggests that approximately 1 7 of all live births do not conform to a Platonic ideal of absolute sex chromosome gonadal genital and hormonal dimorphism 10 9 these publications have been widely quoted by intersex activists 65 66 67 Of the 1 7 percent 1 5 percentage points 88 of those considered nondimorphic sexual development in this figure consist of individuals with late onset congenital adrenal hyperplasia LOCAH which may be asymptomatic but can present after puberty and cause infertility 68 In response to Fausto Sterling Leonard Sax estimated that the prevalence of intersex was about 0 018 of the world s population 4 after discounting several conditions including LOCAH Klinefelter syndrome 47 XXY Turner syndrome 45 X the chromosomal variants of 47 XYY and 47 XXX and vaginal agenesis Sax reasons that in these conditions chromosomal sex is consistent with phenotypic sex and phenotype is classifiable as either male or female 4 In a 2003 letter to the editor political scientist Carrie Hull analyzed the data used by Fausto Sterling and said the estimated intersex rate should instead have been 0 37 due to many errors 69 In a response letter published simultaneously Fausto Sterling welcomed the additional analysis and said I am not invested in a particular final estimate only that there BE an estimate 69 A 2018 review reported that the number of births with ambiguous genitals is in the range of 0 02 to 0 05 3 Intersex Human Rights Australia says it maintains 1 7 as its preferred upper limit despite its flaws stating both that the estimate encapsulates the entire population of people who are stigmatized or risk stigmatization due to innate sex characteristics and that Sax s definitions exclude individuals who experience such stigma and who have helped to establish the intersex movement 70 The following summarizes prevalences of traits that have been called intersex Prevalences of various conditions that have been called intersex Intersex condition Sex specificity Approximate prevalenceLate onset congenital adrenal hyperplasia nonclassical forms Female males are generally asymptomatic 71 One in 50 1 000 births 0 1 0 2 up to 1 2 depending on population 72 Hypospadias Male One in 200 10 000 male births 0 01 0 5 prevalence estimates vary considerably 73 Klinefelter syndrome Male One in 500 1 000 male births 0 1 0 2 74 Trisomy X Female One in 1 000 female births 0 10 75 Turner syndrome Female One in 2 500 female births 0 04 76 Mullerian agenesis of vagina i e MRKH Syndrome Female One in 4 500 female births 0 022 77 Vaginal atresia Female One in 5 000 female births 0 02 78 45 X 46 XY mosaicism Male One in 6 666 births 0 015 79 XYY syndrome Male One in 7 000 male births 0 0142 80 Congenital adrenal hyperplasia classical forms None but virilization of female infants 72 68 One in 10 000 20 000 births 0 01 0 02 68 XXYY syndrome Male One in 18 000 40 000 male births 0 0025 0 0055 81 XX male syndrome Male One in 20 000 male births 0 005 82 True hermaphroditism None One in 20 000 births 0 005 83 XY gonadal dysgenesis Phenotypic female 84 One in 80 000 births 0 0013 85 Androgen insensitivity syndrome complete and partial phenotypes Genetic male 86 One in 99 000 births 0 001 87 Idiopathic no discernable medical cause None One in 110 000 births 0 0009 88 Iatrogenic caused by medical treatment e g progestogen administered to pregnant mother None No estimate5 alpha reductase deficiency Male No estimateAromatase excess syndrome None No estimateAnorchia Male No estimatePersistent Mullerian duct syndrome Male No estimatePrevalences of specific conditions can vary across regions In the Dominican Republic 5 alpha reductase deficiency is not uncommon in the town of Las Salinas resulting in social acceptance of the intersex trait 89 Men with the trait are called guevedoces Spanish for eggs at twelve 12 out of 13 families had one or more male family members that carried the gene The overall incidence for the town was 1 in every 90 males were carriers with other males either non carriers or non affected carriers 90 History EditMain articles Intersex in history Timeline of intersex history and History of intersex surgery Hermaphroditus in a wall painting from Herculaneum first half of the 1st century AD A Chola statue depicting Ardhanarishvara a Hermaphroditus form of Shiva From early history societies have been aware of intersex people Some of the earliest evidence is found in mythology the Greek historian Diodorus Siculus wrote of the mythological Hermaphroditus in the first century BC who was born with a physical body which is a combination of that of a man and that of a woman and reputedly possessed supernatural properties 91 He also recounted the lives of Diophantus of Abae and Callon of Epidaurus 92 Ardhanarishvara an androgynous composite form of male deity Shiva and female deity Parvati originated in Kushan culture as far back as the first century AD 93 A statue depicting Ardhanarishvara is included in India s Meenakshi Temple this statue clearly shows both male and female bodily elements 94 Hippocrates c 460 c 370 BC Greek physician and Galen 129 c 200 216 AD Roman physician surgeon and philosopher both viewed sex as a spectrum between men and women with many shades in between including hermaphrodites a perfect balance of male and female 95 Pliny the Elder AD 23 24 79 the Roman naturalist described those who are born of both sexes whom we call hermaphrodites at one time androgyni from the Greek andr man and gyn woman 96 Augustine 354 28 August 430 AD the influential Catholic theologian wrote in The Literal Meaning of Genesis that humans were created in two sexes despite as happens in some births in the case of what we call androgynes 95 In medieval and early modern 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 97 The 12th century Decretum Gratiani states that Whether an hermaphrodite may witness a testament depends on which sex prevails 98 99 100 The foundation of common law the 17th 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 101 55 Legal cases have been described in canon law and elsewhere over the centuries Some non European societies have sex or gender systems that recognize more than the two categories of male man and female woman Some of these cultures for instance the South Asian Hijra communities may include intersex people in a third gender category 102 103 Although according to Morgan Holmes early Western anthropologists categorized such cultures primitive Holmes has argued that analyses of these cultures have been simplistic or romanticized and fail to take account of the ways that subjects of all categories are treated 104 During the Victorian era medical authors introduced the terms true hermaphrodite for an individual who has both ovarian and testicular tissue male pseudo hermaphrodite for a person with testicular tissue but either female or ambiguous sexual anatomy and female pseudo hermaphrodite for a person with ovarian tissue but either male or ambiguous sexual anatomy Some later shifts in terminology have reflected advances in genetics while other shifts are suggested to be due to pejorative associations 105 The term intersexuality was coined by Richard Goldschmidt in 1917 106 The first suggestion to replace the term hermaphrodite with intersex was made by Cawadias in the 1940s 61 Since the rise of modern medical science some intersex people with ambiguous external genitalia have had their genitalia surgically modified to resemble either female or male genitals Surgeons pinpointed intersex babies as a social emergency when born 107 An optimal gender policy initially developed by John Money stated that early intervention helped avoid gender identity confusion but this lacks evidence 108 Early interventions have adverse consequences for psychological and physical health 34 Since advances in surgery have made it possible for intersex conditions to be concealed many people are not aware of how frequently intersex conditions arise in human beings or that they occur at all 109 Dialogue between what were once antagonistic groups of activists and clinicians has led to only slight changes in medical policies and how intersex patients and their families are treated in some locations 110 In 2011 Christiane Volling became the first intersex person known to have successfully sued for damages in a case brought for non consensual surgical intervention 36 In April 2015 Malta became the first country to outlaw non consensual medical interventions to modify sex anatomy including that of intersex people 37 Many civil society organizations and human rights institutions now call for an end to unnecessary normalizing interventions including in the Malta declaration 111 1 Human rights and legal issues Edit Intersex activists on a boat at Utrecht Canal Pride in the Netherlands on June 16 2018 Further information Intersex rights by country Human rights institutions are placing increasing scrutiny on harmful practices and issues of discrimination against intersex people These issues have been addressed by a rapidly increasing number of international institutions including in 2015 the Council of Europe the United Nations Office of the United Nations High Commissioner for Human Rights and the World Health Organization WHO These developments have been accompanied by International Intersex Forums and increased cooperation amongst civil society organizations However the implementation codification and enforcement of intersex human rights in national legal systems remains slow Physical integrity and bodily autonomy Edit Legal prohibition of non consensual medical interventions Regulatory suspension of non consensual medical interventions Parts of this article those related to map need to be updated Please help update this article to reflect recent events or newly available information May 2021 Main articles Intersex human rights and Intersex medical interventions Stigmatization and discrimination from birth may include infanticide abandonment and the stigmatization of families The birth of an intersex child was often viewed as a curse or a sign of a witch mother especially in parts of Africa 25 26 Abandonments and infanticides have been reported in Uganda 25 Kenya 112 South Asia 113 and China 27 Infants children and adolescents also experience normalising interventions on intersex persons that are medically unnecessary and the pathologisation of variations in sex characteristics In countries where the human rights of intersex people have been studied medical interventions to modify the sex characteristics of intersex people have still taken place without the consent of the intersex person 114 115 Interventions have been described by human rights defenders as a violation of many rights including but not limited to bodily integrity non discrimination privacy and experimentation 116 These interventions have frequently been performed with the consent of the intersex person s parents when the person is legally too young to consent Such interventions have been criticized by the WHO other UN bodies such as the Office of the High Commissioner for Human Rights and an increasing number of regional and national institutions due to their adverse consequences including trauma impact on sexual function and sensation and violation of rights to physical and mental integrity 1 The UN organizations decided that infant intervention should not be allowed in favor of waiting for the child to mature enough to be a part of the decision making this allows for a decision to be made with total consent 117 In April 2015 Malta became the first country to outlaw surgical intervention without consent 37 38 In the same year the Council of Europe became the first institution to state that intersex people have the right not to undergo sex affirmation interventions 65 Anti discrimination and equal treatment Edit Explicit protection on grounds of sex characteristics Explicit protection on grounds of intersex status Explicit protection on grounds of intersex within attribute of sex Main article Discrimination against intersex people People born with intersex bodies are seen as different Intersex infants children adolescents and adults are often stigmatized and subjected to multiple human rights violations including discrimination in education healthcare employment sport and public services 2 Several countries have so far explicitly protected intersex people from discrimination with landmarks including South Africa 118 Australia 119 120 and most comprehensively Malta 121 122 123 Remedies and claims for compensation Edit Main article Intersex human rights Claims for compensation and remedies for human rights abuses include the 2011 case of Christiane Volling in Germany 36 124 A second case was adjudicated in Chile in 2012 involving a child and his parents 125 126 A further successful case in Germany taken by Michaela Raab was reported in 2015 127 In the United States the Minor Child M C v Aaronson lawsuit was a medical malpractice case related to the informed consent for a surgery performed on the Crawford s adopted child known as M C at Medical University of South Carolina in April 2006 128 The case was one of the first lawsuit of its kind to challenge legal ethical and medical issues regarding genital normalizing surgery in minors and was eventually settled out of court by the Medical University of South Carolina for 440 000 in 2017 129 Information and support Edit Main article Intersex human rights Access to information medical records peer and other counselling and support With the rise of modern medical science in Western societies a secrecy based model was also adopted in the belief that this was necessary to ensure normal physical and psychosocial development 130 131 132 Legal recognition Edit Main article Legal recognition of intersex people The Asia Pacific Forum of National Human Rights Institutions states that legal recognition is firstly about intersex people who have been issued a male or a female birth certificate being able to enjoy the same legal rights as other men and women 35 In some regions obtaining any form of birth certification may be an issue A Kenyan court case in 2014 established the right of an intersex boy Baby A to a birth certificate 133 Like all individuals some intersex individuals may be raised as a certain sex male or female but then identify with another later in life while most do not 134 6 135 136 Recognition of third sex or gender classifications occurs in several countries 137 138 139 140 However it is controversial when it becomes assumed or coercive as is the case with some German infants 141 142 Sociological research in Australia a country with a third X sex classification shows that 19 of people born with atypical sex characteristics selected an X or other option while 75 of survey respondents self described as male or female 52 as women 23 as men and 6 as unsure 7 46 LGBT and LGBTI Edit U S intersex activist Pidgeon Pagonis Main article Intersex and LGBT ILGA conference 2018 group photo to mark Intersex Awareness Day Intersex conditions can be contrasted with transgender gender identities and the attached gender dysphoria a transgender person may feel wherein their gender identity does not match their assigned sex 143 144 145 However some people are both intersex and transgender though intersex people by definition have variable sex characteristics that do not align with either typically male or female this may be considered separate to an individual s assigned gender the way they are raised and perceived and their internal gender identity 146 A 2012 clinical review paper found that between 8 5 and 20 of people with intersex variations experienced gender dysphoria 135 In an analysis of the use of preimplantation genetic diagnosis to eliminate intersex traits Behrmann and Ravitsky state Parental choice against intersex may conceal biases against same sex attractedness and gender nonconformity 147 The relationship of intersex people and communities to LGBTQ communities is complex 148 but intersex people are often added to the LGBT acronym resulting in the acronym LGBTI Emi Koyama describes how inclusion of intersex in LGBTI can fail to address intersex specific human rights issues including creating false impressions that intersex people s rights are protected by laws protecting LGBT people and failing to acknowledge that many intersex people are not LGBT 149 Organisation Intersex International Australia states that some intersex individuals are homosexual and some are heterosexual but LGBTI activism has fought for the rights of people who fall outside of expected binary sex and gender norms 150 151 Julius Kaggwa of SIPD Uganda has written that while the gay community offers us a place of relative safety it is also oblivious to our specific needs 152 Mauro Cabral has written that transgender people and organizations need to stop approaching intersex issues as if they were trans issues including use of intersex conditions and people as a means of explaining being transgender we can collaborate a lot with the intersex movement by making it clear how wrong that approach is 153 In society EditFiction literature and media Edit Main articles Literature about intersex and Intersex characters in fiction Kristi Bruce after shooting the documentary XXXY 2000 An intersex character is the narrator in Jeffrey Eugenides Pulitzer Prize winning novel Middlesex The memoir Born Both An Intersex Life Hachette Books 2017 by intersex author and activist Hida Viloria received strong praise from The New York Times Book Review The Washington Post Rolling Stone People Magazine and Psychology Today was one of School Library Journal s 2017 Top Ten Adult Books for Teens and was a 2018 Lambda Literary Award nominee Television works about intersex and films about intersex are scarce The Spanish language film XXY won the Critics Week grand prize at the 2007 Cannes Film Festival and the ACID CCAS Support Award 154 Faking It is notable for providing both the first intersex main character in a television show 155 and television s first intersex character played by an intersex actor 156 Civil society institutions Edit Main article Intersex civil society organizations Intersex peer support and advocacy organizations have existed since at least 1985 with the establishment of the Androgen Insensitivity Syndrome Support Group Australia in 1985 157 The Androgen Insensitivity Syndrome Support Group UK was established in 1988 158 The Intersex Society of North America ISNA may have been one of the first intersex civil society organizations to have been open to people regardless of diagnosis it was active from 1993 to 2008 159 Events Edit Main articles Intersex Awareness Day and Intersex Day of Remembrance Intersex Awareness Day is an internationally observed civil awareness day designed to highlight the challenges faced by intersex people occurring annually on 26 October It marks the first public demonstration by intersex people which took place in Boston on 26 October 1996 outside a venue where the American Academy of Pediatrics was holding its annual conference 160 Intersex Day of Remembrance also known as Intersex Solidarity Day is an internationally observed civil awareness day designed to highlight issues faced by intersex people occurring annually on 8 November It marks the birthday of Herculine Barbin a French intersex person whose memoirs were later published by Michel Foucault in Herculine Barbin Being the Recently Discovered Memoirs of a Nineteenth century French Hermaphrodite Flag Edit Main article Intersex flag Intersex flag The intersex flag was created in July 2013 by Morgan Carpenter of Intersex Human Rights Australia to create a flag that is not derivative but is yet firmly grounded in meaning The circle is described as unbroken and unornamented symbolising wholeness and completeness and our potentialities We are still fighting for bodily autonomy and genital integrity and this symbolises the right to be who and how we want to be 161 Religion Edit Main article Intersex people and religion In Judaism the Talmud contains extensive discussion concerning the status of two types of intersex people in Jewish law namely the androgynous who exhibit both male and female external sexual organs and the tumtum who exhibit neither In the 1970s and 1980s the treatment of intersex babies started to be discussed in Orthodox Jewish medical halacha by prominent rabbinic leaders such as Eliezer Waldenberg and Moshe Feinstein 162 Sport Edit Main article Sex verification in sports Stanislawa Walasiewicz in 1933 Erik Schinegger Foekje Dillema Maria Jose Martinez Patino and Santhi Soundarajan were subject to adverse sex verification testing resulting in ineligibility to compete in organised competitive competition Stanislawa Walasiewicz was posthumously ruled ineligible to have competed 163 The South African middle distance runner Caster Semenya won gold at the World Championships in the women s 800 metres and won silver in the 2012 Summer Olympics When Semenya won gold in the World Championships the International Association of Athletics Federations IAAF requested sex verification tests The results were not released Semenya was ruled eligible to compete 164 Katrina Karkazis Rebecca Jordan Young Georgiann Davis and Silvia Camporesi have claimed that IAAF policies on hyperandrogenism in female athletes are significantly flawed arguing that the policy does not protect against breaches of privacy requires athletes to undergo unnecessary treatment in order to compete and intensifies gender policing and recommended that athletes be able to compete in accordance with their legally recognised gender 165 In April 2014 the BMJ reported that four elite women athletes with XY chromosomes and 5 ARD were subjected to sterilization and partial clitoridectomies in order to compete in sport The authors noted that partial clitoridectomy was not medically indicated and does not relate to real or perceived athletic advantage 29 Intersex advocates who regarded this intervention as a clearly coercive process 166 In 2016 the United Nations Special Rapporteur on health Dainius Puras criticized current and historic sex verification policies describing how a number of athletes have undergone gonadectomy removal of reproductive organs and partial clitoridectomy a form of female genital mutilation in the absence of symptoms or health issues warranting those procedures 167 Biology EditMain article Intersex biology The notion of intersex individuals can be understood in the context of sexual system biology that varies across different types of organisms Most animal species 95 including humans are gonochoric in which individuals are of either a female or male sex 168 Hermaphroditic species some animals and most flowering plants 169 are represented by individuals that can express both sexes simultaneously or sequentially during their lifetimes 170 Intersex individuals in a number of gonochoric species who express both female and male phenotypic characters to some degree 171 are known to exist at very low prevalences Although hermaphrodite and intersex have been used synonymously in humans 172 pages needed a hermaphrodite is specifically an individual capable of producing female and male gametes 173 While there are reports of individuals that seemed to have the potential to produce both types of gamete 174 in more recent years the term hermaphrodite as applied to humans has fallen out of favor since female and male reproductive functions have not been observed together in the same individual 175 Medical EditResearch in the late 20th century led to a growing medical consensus that diverse intersex bodies are normal but relatively rare forms of human biology 6 176 177 178 Clinician and researcher Milton Diamond stresses the importance of care in the selection of language related to intersex people Foremost we advocate use of the terms typical usual or most frequent where it is more common to use the term normal When possible avoid expressions like maldeveloped or undeveloped errors of development defective genitals abnormal or mistakes of nature Emphasize that all of these conditions are biologically understandable while they are statistically uncommon 179 Medical classifications Edit Sexual differentiation Edit Main article Sexual differentiation The common pathway of sexual differentiation where a productive human female has an XX chromosome pair and a productive male has an XY pair is relevant to the development of intersex conditions During fertilization the sperm adds either an X female or a Y male chromosome to the X in the ovum This determines the genetic sex of the embryo During the first weeks of development genetic male and female fetuses are anatomically indistinguishable with primitive gonads beginning to develop during approximately the sixth week of gestation The gonads in a bipotential state may develop into either testes the male gonads or ovaries the female gonads depending on the consequent events 180 Up until and including the seventh week genetically female and genetically male fetuses appear identical At around eight weeks of gestation the gonads of an XY embryo differentiate into functional testes secreting testosterone Ovarian differentiation for XX embryos does not occur until approximately week 12 of gestation In typical female differentiation the Mullerian duct system develops into the uterus Fallopian tubes and inner third of the vagina In males the Mullerian duct inhibiting hormone MIH causes this duct system to regress Next androgens cause the development of the Wolffian duct system which develops into the vas deferens seminal vesicles and ejaculatory ducts 180 By birth the typical fetus has been completely sexed male or female meaning that the genetic sex XY male or XX female corresponds with the phenotypical sex that is to say genetic sex corresponds with internal and external gonads and external appearance of the genitals Signs Edit There are a variety of symptoms that can occur Ambiguous genitalia is the most common sign There can be micropenis clitoromegaly partial labial fusion electrolyte abnormalities delayed or absent puberty unexpected changes at puberty hypospadias labial or inguinal groin masses which may turn out to be testes in girls and undescended testes which may turn out to be ovaries in boys 181 Ambiguous genitalia Edit Ambiguous genitalia may appear as a large clitoris or as a small penis The Quigley scale is a method for describing genital development in AIS Because there is variation in all of the processes of the development of the sex organs a child can be born with a sexual anatomy that is typically female or feminine in appearance with a larger than average clitoris clitoral hypertrophy or typically male or masculine in appearance with a smaller than average penis that is open along the underside The appearance may be quite ambiguous describable as female genitals with a very large clitoris and partially fused labia or as male genitals with a very small penis completely open along the midline hypospadic and empty scrotum Fertility is variable citation needed Measurement systems for ambiguous genitalia Edit The orchidometer is a medical instrument to measure the volume of the testicles It was developed by Swiss pediatric endocrinologist Andrea Prader The Prader scale 182 and Quigley scale are visual rating systems that measure genital appearance These measurement systems were satirized in the Phall O Meter created by the now defunct Intersex Society of North America 183 184 185 Other signs Edit In order to help in classification methods other than a genitalia inspection can be performed For instance a karyotype display of a tissue sample may determine which of the causes of intersex is prevalent in the case Additionally electrolyte tests endoscopic exam ultrasound and hormone stimulation tests can be done 186 Causes Edit Intersex can be divided into four categories which are 46 XX intersex 46 XY intersex true gonadal intersex and complex or undetermined intersex 181 46 XX intersex Edit This condition used to be called female pseudohermaphroditism Persons with this condition have female internal genitalia and karyotype XX and various degree of external genitalia virilization 187 External genitalia is masculinized congenitally when female fetus is exposed to excess androgenic environment 181 Hence the chromosome of the person is of a woman the ovaries of a woman but external genitals that appear like a male The labia fuse and the clitoris enlarges to appear like a penis The causes of this can be male hormones taken during pregnancy congenital adrenal hyperplasia male hormone producing tumors in the mother and aromatase deficiency 181 46 XY intersex Edit This condition used to be called male pseudohermaphroditism This is defined as incomplete masculinization of the external genitalia 188 Thus the person has male chromosomes but the external genitals are incompletely formed ambiguous or clearly female 181 189 This condition is also called 46 XY with undervirilization 181 46 XY intersex has many possible causes which can be problems with the testes and testosterone formation 181 Also there can be problems with using testosterone Some people lack the enzyme needed to convert testosterone to dihydrotestosterone which is a cause of 5 alpha reductase deficiency 181 Androgen insensitivity syndrome is the most common cause of 46 XY intersex 181 True gonadal intersex Edit This condition used to be called true hermaphroditism This is defined as having asymmetrical gonads with ovarian and testicular differentiation on either sides separately or combined as ovotestis 190 In most cases the cause of this condition is unknown Complex or undetermined intersex Edit This is the condition of having any chromosome configurations rather than 46 XX or 46 XY intersex This condition does not result in an imbalance between internal and external genitalia However there may be problems with sex hormone levels overall sexual development and altered numbers of sex chromosomes 181 Conditions Edit Further information Disorders of sex development There are a variety of opinions on what conditions or traits are and are not intersex dependent on the definition of intersex that is used Current human rights based definitions stress a broad diversity of sex characteristics that differ from expectations for male or female bodies 2 During 2015 the Council of Europe 65 the European Union Agency for Fundamental Rights 191 and Inter American Commission on Human Rights 192 have called for a review of medical classifications on the basis that they presently impede enjoyment of the right to health the Council of Europe expressed concern that the gap between the expectations of human rights organisations of intersex people and the development of medical classifications has possibly widened over the past decade 65 191 192 Medical interventions Edit Hong Kong intersex activist Small Luk Main article Intersex medical interventions Further information History of intersex surgery Rationales Edit Medical interventions take place to address physical health concerns and psychosocial risks Both types of rationale are the subject of debate particularly as the consequences of surgical and many hormonal interventions are lifelong and irreversible Questions regarding physical health include accurately assessing risk levels necessity and timing Psychosocial rationales are particularly susceptible to questions of necessity as they reflect social and cultural concerns There remains no clinical consensus about an evidence base surgical timing necessity type of surgical intervention and degree of difference warranting intervention 193 194 195 Such surgeries are the subject of significant contention due to consequences that include trauma impact on sexual function and sensation and violation of rights to physical and mental integrity 1 This includes community activism 105 and multiple reports by international human rights 31 65 35 196 and health 132 institutions and national ethics bodies 34 197 In the cases where gonads may pose a cancer risk as in some cases of androgen insensitivity syndrome 198 concern has been expressed that treatment rationales and decision making regarding cancer risk may encapsulate decisions around a desire for surgical normalization 33 Types Edit Feminizing and masculinizing surgeries Surgical procedures depend on the diagnosis and there is often a concern as to whether surgery should be performed at all Typically surgery is performed shortly after birth Defenders of the practice argue that individuals must be clearly identified as male or female for them to function socially and develop normally Psychosocial reasons are often stated 21 This is criticised by many human rights institutions and authors Unlike other aesthetic surgical procedures performed on infants such as corrective surgery for a cleft lip genital surgery may lead to negative consequences for sexual functioning in later life or feelings of freakishness and unacceptability 199 Hormone treatment There is widespread evidence of prenatal testing and hormone treatment to prevent or eliminate intersex traits 200 associated also with the problematization of sexual orientation and gender non conformity 200 201 Psychosocial support All stakeholders support psychosocial support A joint international statement by participants at the Third International Intersex Forum in 2013 sought amongst other demands Recognition that medicalization and stigmatisation of intersex people result in significant trauma and mental health concerns In view of ensuring the bodily integrity and well being of intersex people autonomous non pathologising psycho social and peer support be available to intersex people throughout their life as self required as well as to parents and or care providers This quote needs a citation Genetic selection and terminations The ethics of preimplantation genetic diagnosis to select against intersex traits was the subject of 11 papers in the October 2013 issue of the American Journal of Bioethics 202 There is widespread evidence of pregnancy terminations arising from prenatal testing as well as prenatal hormone treatment to prevent intersex traits Behrmann and Ravitsky find social concepts of sex gender and sexual orientation to be intertwined on many levels Parental choice against intersex may thus conceal biases against same sex attractedness and gender nonconformity 147 Medical display Photographs of intersex children s genitalia are circulated in medical communities for documentary purposes and individuals with intersex traits may be subjected to repeated genital examinations and display to medical teams Problems associated with experiences of medical photography of intersex children have been discussed 203 along with their ethics control and usage 204 205 The experience of being photographed has exemplified for many people with intersex conditions the powerlessness and humiliation felt during medical investigations and interventions 204 Gender dysphoria The DSM 5 included a change from using gender identity disorder to gender dysphoria This revised code now specifically includes intersex people who do not identify with their sex assigned at birth and experience clinically significant distress or impairment using the language of disorders of sex 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Office of the High Commissioner for Human Rights World Health Organization OHCHR UN Women UNAIDS UNDP UNFPA UNICEF 2014 Eliminating forced coercive and otherwise involuntary sterilization An interagency statement PDF ISBN 978 92 4 150732 5 Zwischengeschlecht March 2014 IGM Historical Overview Hermaphrodites in the Developed World From Legal Self Determination to IGM Supplement 1 PDF NGO Report to the 2nd 3rd and 4th Periodic Report of Switzerland on the Convention on the Rights of the Child CRC 2 ed pp 49 62 External links Edit Media related to Intersex at Wikimedia Commons External video What It s Like To Be Intersex Lizz Warner BuzzFeed The template below Female congenital anomalies of genital organs is being considered for merging See templates for discussion to help reach a consensus The template below Male congenital anomalies of genital organs is being considered for merging See templates for discussion to help reach a consensus Retrieved from https en wikipedia org w index php 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