By Emma Mas
Do you know if you’re having a boy or a girl yet?
This is likely one of the first questions you received, after you received congratulations on your pregnancy. In the first trimester, maybe someone dangled a ring on a string over your belly. In the second trimester, maybe you had a revealing ultrasound. Maybe you’ve decided to wait until you meet your baby. But how does a baby come to be assigned male or female, and are those our only outcomes?
Sex is a configuration of several parts. Our chromosomes, internal reproductive systems, genitals, and hormones all contribute to what is currently defined as sex. This does not include the secondary sex characteristics that develop in puberty, nor one’s gender identity or presentation. Yet babies are often assigned male at birth (AMAB) or assigned female at birth (AFAB), just based on the appearance of their genitals. Other times, a newborn’s genitals do not align with medicalized expectations for male or female classifications, welcoming new parents into the fold of an unexpected, ongoing, and contentious conversation.
Intersex is defined by the World Health Organization as, “a congenital anomaly of the reproductive and sexual system”. Meaning that people are born intersex, and while the origins are related to one’s sexual configuration, it is an umbrella term without fully defined parameters. Note that intersex bodies are medically defined as an “anomaly”, though we don’t have an accurate picture of the prevalence of intersex people.
Some groups cite an old statistic that roughly 1 per 2,000 (0.05%) babies are born visibly intersex, meaning they have ambiguous genitalia. Of course, this does not include the intersex variations which cannot be visually assessed, often chromosomal or hormonal, and may or may not be discovered later in life. Other studies, which account for all intersex conditions place the estimate closer to 1.7% of births. As common as having red hair. Still, this estimate can be misleading by collapsing all intersex variations into one category, though some are known to be more common than others. We still have a lot to learn, which means we need to ask important questions.
With no concrete parameters, and a lack of knowledge of prevalence, how can intersex bodies be called an anomaly? Why are some bodies considered less natural than others? How do our bodies come to be? And how do we then come to be assigned as intersex, female, or male?
Your baby’s sexual development began at conception. The ovum and the sperm that made your baby likely donated one sex chromosome each to form the zygote. There are less common developments as well, a few births per thousand, where babies will have a single sex chromosome (monosomies). As well as births with three or more sex chromosomes (polysomies). Ova can only provide X chromosomes, while sperm can either provide X or Y chromosomes. If your baby has two X chromosomes, one from the ovum and one from the sperm, they are considered ‘genetically female’. If your baby has one X chromosome from the ovum, and one Y chromosome from the sperm, then they are considered ‘genetically male’.
An example of monosomy is Turner syndrome. Turner syndrome is also called monosomy X, as people with Turner syndrome have only one sex chromosome: the X. People with Turner syndrome experience abnormal growth patterns, are generally shorter than people with two X chromosomes, do not develop feminine secondary sex characteristics, and are infertile. Compare this with a polysomy (called Triple X syndrome) where people have not one X chromosome, but three. With three X chromosomes, people develop feminine secondary sex characteristics, and are generally taller than people with XX chromosomes. Triple X syndrome is more common than Turner syndrome.
The most common intersex variation related to chromosomes is Klinefelter syndrome, which is diagnosed in 1 in 600 people AMAB. People with Klinefelter syndrome have two or more X chromosomes, in addition to their Y chromosome. People with Klinefelter syndrome are often tall, infertile, and produce low testosterone – as a result, their secondary masculine sex characteristics are often not fully developed. Chromosomes are just the first piece in the larger mosaic of how sex is assigned, as they prompt further development of internal reproductive systems.
All fetuses, regardless of their chromosomes, have the capacity to develop either ‘male’ and ‘female’ internal reproductive systems. These systems rely on cues from the fetal body to develop further. You may have heard we are all ‘female’ in utero, unless a ‘male’ system develops. This is somewhat misleading. In truth, we all had universal potential, by possessing two internal reproductive systems. These systems are called the Wolffian (‘male’) and Müllerian (‘female’) systems. The Wolffian system must be prompted in order to develop, while the Müllerian system will develop without additional cues. Gonads, which develop as ovaries or testicles, are neither Wolffian nor Müllerian. Internal reproductive system development is prompted by chromosomes, but it is fetal hormones which sustain and influence their course.
Congenital Adrenal Hyperplasia, sometimes called Androgenital Syndrome, results from low cortisol during development. It can affect anyone regardless of their chromosomal arrangement, however people with XX chromosomes will develop a masculinized appearance as a result. Androgen Insensitivity Syndrome is the name for people who develop external feminine genitals and secondary sex characteristics despite having XY (‘genetically male’) chromosomes. A study which interviewed people with Androgen Insensitivity Syndrome, found that each participant was satisfied with having being raised feminine. All identified as women, and none desired surgical or hormonal alterations to their body. Most were satisfied with their psychosexual development and their sexual function.
The medical community and intersex advocates have historically had conflicting views on intersex bodies. The broader medical community diagnoses them as having disorders of sex development (DSD), defines being intersex as an abnormality, and urges parents to consent to “corrective” or “normalizing” surgery. Intersex advocates have chosen the term intersex for themselves, consider being intersex a variation rather than an abnormality, and urge parents not to consent to elective surgeries, but rather to consider the risks of surgeries to their child’s physical, psychological, and emotional health.
If you learn your child is intersex at birth, our recommendation is to take your time. Find relief in the knowledge that you have all the time you need to learn about your baby before any choices will present themselves. Surely, this is just one of many ways your child will surprise, challenge, and delight you throughout their life! Find out what specific intersex variation they have, as each is unique, and educate yourself what that specific variation means for their development throughout their life. Find a community to connect with intersex people and their family members, you are a member of this community and you are welcome here.
Some people go their entire lives without knowing they are intersex, as many intersex variations cannot be visually assessed and do not inherently pose any identifiable symptoms or conditions. Some people find out when trying to conceive, others during puberty. You may be the first to know your child is intersex, when you first meet.
Certainly someone has asked you. Consider it yourself, do you know if you’re having a boy or a girl yet?
Emma Mas is an apprentice with The Childbearing Society, and a doula working towards DONA certification. She’s originally from Seattle, but made a home in Vancouver after graduating from UBC with a degree in Psychology and Family Studies. She came to birth work while working as BC Women’s Hospital, meeting thousands of families shortly after birth, though her position as the Coordinator of the UBC Early Development Research Group.