Are Intersex Children Boys or Girls?

What to Do When Ontological Identity Isn't Clear

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WASHINGTON, D.C., MAY 9, 2012 (Zenit.org).- Here is a continued discussion of a question on bioethics answered by the fellows of the Culture of Life Foundation.

By E. Christian Brugger

In my last column titled "The New Pangenderism" I mentioned a condition called "intersex," in which the sex of a child, because of the anomalous formation of physical characteristics that ordinarily distinguish a male from a female, can be very difficult to determine.

Formerly referred to as "hermaphroditism" (from the names of the Greek deities Hermes and Aphrodite, the male and female gods of sexuality), intersex is actually a group of conditions under the larger category of disorders of sex development. Because of genetic and/or anatomical abnormalities, a child may possess both male and female biological characteristics. They may have ovaries, a partial or whole uterus and a penis, or an abnormally large clitoris that appears like a penis. Or they may have a partially formed vagina, with one ovary and one testicle, or rudimentary tissue of both ("ovotestes"), or just one, or neither. The discrepancy between the external genitals (penis, vagina) and the internal genitals (the testes and ovaries) may be coupled with chromosomal anomalies. Rather than the ordinary patterns of sex chromosomes (XX-female or XY-male), they may have only a single sex chromosome (XO), or an extra sex chromosome (XXY or XXX), or chromosomal sex reversal (XY-female, XX-male). The condition is quite rare; conservative estimates put the number at about 1 in 4,500 births (others say as many as 1 in 2,000), roughly as prevalent as cystic fibrosis.

In the past, doctors routinely responded to an intersex birth by recommending genital surgery, more often than not, the construction of female genitals since vaginas were easier to make than penises. This was the case whether or not the sex of the child was a settled fact. The trend was partially due to the bogus theories on sex and gender of the infamous Johns Hopkins psychologist and "sexologist" John Money (1921-2006). Money drove a wedge between the concepts of "genital sex," a crude function of biology, he thought, and "gender identity," which he believed was more basic to personal identity and was the product of how a child was raised (i.e., was "socially constructed"). 

When Money came across the boy David Reimer in 1966, victim of a botched circumcision that burned off most of his penis, the reckless doctor recommended that physicians "reassign" the boy as a female by amputating his testicles, surgically constructing a vagina, pumping him full of female hormones to "feminize" him and raising him as a girl (David was given the name "Brenda"). The vicious experiment was a total failure. David lived a tortured life of confused identity, later rejecting his imposed female identity and finally shooting himself in the head in 2004 at the age of 38 (see the excellent but horrifying story of David Reimer in John Colapinto's, "As Nature Made Him: The Boy Who Was Raised as a Girl").

The brazen sexologist was celebrated as a far-sighted harbinger of sexual liberation (including open marriages, pornography and consensual pedophilia) until Milton Diamond exposed the truth about the Reimer case in the late 1990s. The unrepentant Money insisted to the end that the negative response to the exposé was a product of right-wing media bias and "the antifeminist movement," complaining that "(his opponents) say masculinity and femininity are built into the genes so women should get back to the mattress and the kitchen." So much for David Reimer.

In the last 10 years, clinical overconfidence on how best to respond to intersex births has moderated. Most doctors reject the Money thesis that gender is malleable enough to erase and reassign at will. But according to the Intersex Society of North America (ISNA), there is still a tendency to rush to "cure" the condition early on by using surgical, hormonal and psychological treatments. The ISNA points to numerous cases where individuals have suffered severe psychological and physical damage as a result of gender rush-to-judgments and subsequent treatments by doctors. The society has done a great deal of good advocating for a "patient centered" approach to the condition: for telling intersex children and adults the truth, for unconditionally accepting them, and for raising awareness in the community about the sufferings they often experience. 

Unfortunately, the ISNA simultaneously advocates a pangenderist view of sex and gender. It denies that every human person is either male or female, that intersex is an anatomical/chromosomal disorder, and that any "normalizing" intervention is necessary. It asserts that the condition is merely an "anatomical variation from the ‘standard' male and female types"; just as the color of one's skin, eyes or hair vary along a normal continuum, "so does sexual and reproductive anatomy. Intersex is neither a medical nor a social pathology" (reference). Its members seem to believe that if we admit that intersex is a genuine disorder of sex development, we necessarily endorse the view that intersex individuals have less value than those without the condition and that concealment and manipulation are justified.

Catholic teaching 

To my knowledge, no official Catholic teaching has addressed the problem of the intersex condition. My comments therefore should not be taken as settled Church teaching. Yet the following points seem to me to be consistent with what the Catholic faith does hold and teach. 

First, because of the Christian doctrine of creation, especially the teaching of Divine Revelation that human persons are made "in the image of God … male and female" (Genesis 1:26-27), we must reject the view that the intersex condition represents a person who is not or may not be either ontologically male or female. It may be difficult, even effectively impossible to determine with certitude; but our lack of certitude should not be taken as an indication of a factual ambiguity about the nature of the intersex person, only ambiguity in our measure of knowledge. 

Second, if the sex of a child is certain, as it may be in the case of some partial intersex conditions, then, I believe, parents are justified in adopting therapeutic interventions aimed at correcting the disorder and normalizing the body anatomy and chemistry in line with the child's sex.

Having said this, any rush-to-judgment as to the question of the child's sex and hence any simplistic surgical assignment of sexual identity would be gravely immoral because it would be unfair to the child. A parent's discomfort at his or her child's condition, fear of embarrassment -- "it's just not normal" -- is not in itself a reason to surgically assign a sex in the absence of clear evidence. And clear evidence may be elusive. 

Parents should have "moral certitude" of their child's sex before they make permanent surgical interventions determining the sex in one direction or the other. Moral certitude is reached when all reasonable doubts to the contrary have been dispelled.

Does the absence of moral certitude mean that parents should raise an intersex child genderless, or as a kind of "third gender"? No. The ISNA recommends, and it seems to me reasonably, that after rigorous testing (hormonal, genetic, diagnostic) and consultation with other families with intersex children -- and, we should add, for Christians, after importunate prayer to God on the child's behalf (cf. Luke 18:1-8) -- parents should "assign" a gender to their child based upon the best evidence; which means they make a provisional judgment regarding the child's sex and raise the child consistent with that judgment. But they avoid going to the extent of genital assignment surgery. 

The parents and doctors then carefully observe the child over time. If serious reasons arise for reassessing their original judgment, then a careful reassessment with the assistance of trustworthy experts should be undertaken. If the child adjusts well, then they should continue confidently to raise him consistent with their original decision. They should always tell the child the truth about his or her condition as appropriate to his or her age. Later, when the child is more mature, perhaps after puberty, they assist the child, without undue pressure, to make the best decision possible about further interventions. The goal throughout is to identify and then support the child in knowing and embracing the sex that God made him or her.

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E. Christian Brugger is a Senior Fellow of Ethics and director of the Fellows Program at the Culture of Life Foundation; and the J. Francis Cardinal Stafford Chair of Moral Theology at St. John Vianney Theological Seminary in Denver, Colorado.

[Readers may send questions regarding bioethics to bioethics@zenit.org. The text should include your initials, your city and state, province or country. The fellows at the Culture of Life Foundation will answer a select number of the questions that arrive.]