Thoughts? In the US, 1 in 2000 babies are born with ambiguous genitalia. Consider how this has been dealt with before relatively modern medicine and instruments.
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Main articles: Intersex medical interventions and History of intersex surgery
Observation or recognition of an infant's sex may be complicated in the case of intersex infants and children, and in cases of early trauma. In such cases, sex assignment is generally taken to require medical treatment to confirm that assignment, but this is disputed in part due to the human rights implications of such treatment.[7][17]
Intersex is a broadly defined term that usually denotes the presence of atypical sex characteristics: at least some aspect of the genitalia, internal organs, secondary sex characteristics, gonadal tissue, or chromosomes is more typical of the other sex. When the external genitalia appear to be in between, they are described as ambiguous.[18] The intersex population is one that is not necessarily large. In the U.S., about 1 in 2000 babies born are intersex. Due to nonconsensual reassignment surgery many intersex people go about their lives in the gender that was chosen for them in a lot of cases. Not having the choice to choose their own gender can lead to depression and anxiety due to confusion and possible isolation.[19]
Cases of trauma include the famous John/Joan case, where sexologist John Money claimed successful reassignment from male to female at age 17 months of a boy whose penis was destroyed during circumcision. However, this claim was later shown to be largely false. The subject, David Reimer, later identified as a man.
In approximately 1 in 2,000 infants, there is enough variation in the appearance of the external genitalia to merit hesitation about appropriate assignment by the physician involved.[20] Typical examples would be an unusually prominent clitoris in an otherwise apparently typical girl, or complete cryptorchidism in an otherwise apparently typical boy. In most of these cases, a sex is tentatively assigned and the parents told that tests will be performed to confirm the apparent sex. Typical tests in this situation might include a pelvic ultrasound to determine the presence of a uterus, a testosterone or 17α-hydroxyprogesterone level, and/or a karyotype. In some of these cases a pediatric endocrinologist is consulted to confirm the tentative sex assignment. The expected assignment is usually confirmed within hours to a few days in these cases.
In a much smaller proportion of cases, the process of assignment is more complex, and involves both determining what the biological aspects of sex may be and choosing the best sex assignment for the purposes of rearing the child. Approximately 1 in 20,000[citation needed] infants is born with enough ambiguity that assignment becomes a more drawn-out process of multiple tests and intensive education of the parents about sexual differentiation. In some of these cases, it is clear that the child will face physical difficulties or social stigma as he or she grows up, and deciding upon the sex of assignment involves weighing the advantages and disadvantages of either assignment.
History
Nothing currently appears to be known about sex discernment prior to the medicalization of intersex. However, in European societies, Roman law, post-classical Canon law, and later Common law, referred to a person's sex as male, female or hermaphrodite, with legal rights as male or female depending on the characteristics that appeared most dominant. Under Roman law, a hermaphrodite had to be classed as either male or female.[21] The 12th-century Decretum Gratiani states that "Whether an hermaphrodite may witness a testament, depends on which sex prevails".[22][23][24] The foundation of common law, the 16th Century Institutes of the Lawes of England described how a hermaphrodite could inherit "either as male or female, according to that kind of sexe which doth prevaile."[25][26] Legal cases where sex assignment was placed in doubt have been described over the centuries.
With the medicalization of intersex, criteria for assignment have evolved over the decades, as clinical understanding of biological factors and diagnostic tests have improved, as surgical techniques have changed and potential complications have become clearer, and in response to the outcomes and opinions of adults who have grown up with various intersex conditions.
Before the 1950s, assignment was based almost entirely on the appearance of the external genitalia. Although physicians recognized that there were conditions in which the apparent secondary sexual characteristics could develop contrary to the person's sex, and conditions in which the gonadal sex did not match that of the external genitalia, their ability to understand and diagnose such conditions in infancy was too poor to attempt to predict future development in most cases.
In the 1950s, endocrinologists developed a basic understanding of the major intersex conditions such as congenital adrenal hyperplasia (CAH), androgen insensitivity syndrome, and mixed gonadal dysgenesis. The discovery of cortisone allowed survival of infants with severe CAH for the first time. New hormone tests and karyotypes allowed more confident diagnosis in infancy and prediction of future development.
Sex assignment became more than choosing a sex of rearing, but also began to include surgical treatment. Undescended testes could be retrieved. A greatly enlarged clitoris could be amputated to the usual size, but attempts to create a penis were unsuccessful. John Money and others controversially believed that children were more likely to develop a gender identity that matched sex of rearing than might be determined by chromosomes, gonads, or hormones. The resulting medical model was termed the "Optimal gender model."[27]
The view of gender as a purely social construction, and gender identity as a result of nurture rather than nature reached near-universal acceptance, especially among liberal, progressive, and academic portions of Western society. The primary goal of assignment was to choose the sex that would lead to the least inconsistency between external anatomy and assigned psyche (gender identity). This led to the recommendation that any child without a penis or with a penis too small to penetrate a vagina could be raised as a girl, taught to be a girl, and would develop a female gender identity, and that this would be the best way to minimize future discrepancy between psyche and external anatomy in those infants determined to be biologically male but without a penis that meets medical norms (e.g., cloacal exstrophy), and also in those like in the John/Joan case who lost it to accidental trauma in early infancy.
From the 1960s, pediatric surgeons attempted and claimed success with reconstruction of infant genitalia, especially enlargement or construction of vaginas. The recommended rules of assignment and surgery from the late 1960s until the 1990s were roughly:
Any XX infant, no matter how virilized, should be raised as a girl to preserve the chance of future fertility. A large, protruding clitoris should be reduced in size with a nerve-sparing recession or reduction rather than simple amputation.
Any undervirilized XY infant should be raised as a boy if the penis could be expected to be large enough to stand to urinate and to insert into a vagina for coitus. If it was too small or atypically formed (e.g., cloacal exstrophy) for these functions, it was recommended that the baby be assigned as female, any gonads removed, a vaginal opening surgically constructed, and estrogen provided at puberty.
An infant with mixed chromosomes (e.g., mixed gonadal dysgenesis or true hermaphroditism) could be raised either way depending on appearance of genitalia and size of phallus.
Gender identity is set by 2 years of age and reassignment after that age should not be attempted unless requested by the patient.[citation needed]
Non-disclosure of the intersex condition to the individual on whom sex assignment treatment was conducted.[28][29]
Since the 1990s, a number of factors have led to changes in the recommended criteria for assignment and surgery. These factors have included:
Public disclosure by intersex individuals and organizations about unsatisfactory sexual function or incongruent gender identity, and criticism of infant surgery for "psychosocial rationales".
In 1997, the rest of David Reimer's story, referred to above as John Money's John/Joan case, was made public. He was the boy who had lost his penis to a botched circumcision at 8 months in 1966, was reassigned from boy to girl at 18 months with further surgery to remove testes and estrogen treatment beginning at age 12. Although John Money had described the reassignment as a success in the 1970s, Reimer went public with his account of continuing to have a male gender identity despite the reassignment to a female sex of rearing. At age 15, Reimer reverted to living as a male. At age 38, he committed suicide.
A large proportion of XY infants born with cloacal exstrophy and raised as female from early infancy have requested reassignment to male gender in late childhood and adolescence.
Clinical recommendations in the 2000s for assignment changed as a result:
Raise nearly all XX infants with functional ovaries as female. The only rare exception would be completely and unambiguously virilized XX infants with CAH, who might be raised as male with genital surgery deferred.
Raise most ambiguous XY infants with testes as male unless the external genitalia are more female than male, marked androgen insensitivity is present, and testes are absent or non-functional. Raise as male any XY infant with unambiguous micropenis. Raise as male any XY infant with functional testes and normal androgen sensitivity but atypically formed or absent penis.
Raise infants with mixed gonadal tissue, true hermaphroditism, or other chromosome anomalies as the sex most consistent with external genitalia, since gonads are usually nonfunctional.
Gender identity is set by 1?2 years of age and reassignment after that age should not be attempted unless requested by the patient.
These recommendations do not explicitly necessitate surgical or hormonal interventions to reinforce sex assignments, but such medical management persists worldwide, utilizing rationales such as the mitigation of parental distress and trauma, reducing the likelihood of stigma, making a child feel more "normal", and improving marriage prospects.
