Sex assignment refers to the discernment of the biological sex at the birth of a baby. In the majority of births, a relative, midwife, nurse or physician inspects the genitalia when the baby is delivered, sees ordinary male or female genitalia, and declares, "it's a girl" or "it's a boy" without the expectation of ambiguity. Assignment may also be done prior to birth through prenatal sex discernment. Even though the term "assignment" suggests a choice or decision on the part of the parents or medical professionals, the act is almost universally considered a recognition of an essential aspect of a baby. In nearly all cases, the parents rear the child as a member of the assigned sex/gender.
The act of assignment carries the implicit expectation that future gender identity will develop in the gender of anatomy, assignment, and rearing.
In rare cases, the assigned sex or one or more of these related observations and conclusions is found to be incorrect. In the case of some transgender individuals or intersex individuals, gender identity is not consistent with the assigned sex or sex of rearing. There have also been rare instances where parents (for a variety of reasons) have reared an anatomically typical child as if he or she were of the opposite gender. In some conditions, usually termed intersex, internal anatomy may not be consistent with conclusions drawn based on observation of external anatomy.
Intersex is a broadly defined term that usually denotes the presence of discordance of the biological aspects of sex: at least some aspect of the genitalia, internal organs, gonadal tissue, or chromosomes is more typical of the other sex, or incompletely differentiated. When the external genitalia appear to be in between, they are described as ambiguous.
In approximately 1 in 5,000 infants, there is enough variation in the appearance of the external genitalia to merit hesitation about appropriate assignment by the physician involved. Typical examples would be an unusually prominent clitoris in an otherwise apparently normal girl, or complete cryptorchidism or mild hypospadias in an otherwise apparently normal 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 17-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 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 major discordances or abnormalities of anatomy or function as he or she grows up, and deciding upon the sex of assignment involves weighing the advantages and disadvantages of either assignment.
Criteria for assignment in these cases have evolved over the decades, as our understanding of the biological factors and our 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.
The following is a brief review of the history of the criteria for sex assignment in intersex cases.
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: (congenital adrenal hyperplasia (CAH), androgen insensitivity syndrome, mixed gonadal dysgenesis and other chromosomal abnormalities. 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. Surgeons began to devise techniques for repairing the perceived abnormalities of the genitalia. Undescended testes could be retrieved, and hypospadias and chordee usually successfully assigned. A greatly enlarged clitoris could be amputated to the usual size, but attempts to create a penis were unsuccessful. John Money and others observed that children with the same types of intersex conditions might have been raised as different genders and were more likely to develop a gender identity that matched sex of rearing than sex of chromosomes, gonads, or hormones. He also reported that gender identity was usually developed and set by early childhood, such that attempts by parents and doctors to reassign sex at an older age was rarely successful. Endocrinologists and surgeons began to base sex assignment in difficult cases not just on the external genitalia but on the internal genitalia, on the expected future response to testosterone, and on potential fertility.
In the 1960s, surgical confidence with birth defect advanced, as did the acceptability and experience with adult sex reassignment surgery. Pediatric surgeons attempted and claimed success with reconstruction of infant genitalia, especially enlargement or construction of vaginas. 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 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 few biologically male infants unfortunate enough to be born with an irreparably defective penis (e.g., cloacal exstrophy), or to lose it to accidental trauma in early infancy. In the John/Joan case, John Money claimed successful reassignment at 17 months of age from male to female of a boy whose penis was destroyed during circumcision. However, this claim was later shown to be largely false, and the subject later identified as a man (see below).
The recommended rules of assignment and surgery from the late 1960s until the 1990s were roughly:
These continued to be the most commonly used criteria for assignment until the mid-1990s, with one modification. With the recognition in the late 1970s that many cases of micropenis could be treated with hormones, female assignment for unambiguous micropenis went from "recommended but uncommonly" done to "rarely" done.
In the last decade a number of factors have led to changes in the recommended criteria for assignment and surgery. These factors have included:
Current recommendations for assignment in cases of intersex and other birth defects of the genitalia:
Controversies have continued in this decade over surgical aspects of intersex management, especially indications for surgery and optimal timing, but the revised assignment recommendations have been nearly universally accepted.
Sex reassignment refers to a change in gender role or identity after an original and presumably incorrect sex assignment in infancy. This may occur in several types of circumstances.
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