Definitions of intersex

The definition of what is an intersex condition is controversial. Ambiguous genitalia occurs in roughly 0.5% of all births, usually to masculinization or feminization during pregnancy, these conditions range from full androgen insensitivity syndrome, to ovotesticular syndrome. 1.5% of people are born with a disorder of sexual development (DSD consortium), such as those with Klinefelter's syndrome. The DSD was specifically made to be as inclusive to atypical sexual development, not all conditions within the DSD are not medicalized to the same extent. Most intersex activism is based around the end of unnecessary medical interventions on intersex youth which attempt to assign an arbitrary sex and gender binary with no input from the child. Intersex conditions are usually expanded to include the DSD more generally. While 0.5% of all births are born with atypical genitalia only 0.05% of births are medically treated, or considered to be "truly" ambiguous.

The exact definition between male and female in an intersex context is largely arbitrary. Likewise the definition of biological sex is also often considered to be arbitrary as an example in extreme cases individuals with XY female with ovotesticular syndrome and SRY inactivation may have a uterus, ovaries and be able to achieve pregnancy, and many also undergo normal menstruation. These individuals would be declared to be biologically female, but karyotypically male. Likewise many intersex individuals are born completely sterile, although medical interventions have known to remove potentially fertile gonads, which makes sex determination often arbitrary. Individuals with XX male develop male genitalia however, are entirely infertile due to a lack of SRY gene expression, and develop a generally feminine body. This is further expanded by conditions which effect genital development but not hormonal or sex gene expression.

Causes of intersex development

Certain individuals may have a masculinized clitorises or feminized penis, however this might change after pregnancy. The exact differentiation of ovotestis of intersex people are often ambiguous. Other cases of intersex conditions can occur when hormones are taken during pregnancy such as estrogens or androgens, which can lead to atypical sexual development. Commonly intersex people are defined as those who are born with ambiguous genitalia, usually within the context of the OGR, or individuals with substantial atypical sexual development such as those with XX male.

Most conditions under the DSD are not apparent at birth, and most are not medicalized. Certain definitions declare the need for masculinization or feminization of the brain and the body to declare an intersex condition. Under this definition, cloacal exstrophy a rare condition which is caused by the stomach internal organs developing incorrectly would not be intersex. Individuals with cloacal exstrophy who are born with XY do not develop a penis and are usually castrated and assigned female at birth. These people are medicalized like other people with intersex conditions and the OGR model. Due to this individuals with cloacal exstrophy are often considered intersex. InterACT the leading organization of intersex rights in the US states that 1.5% of children are born with an intersex condition (DSD), 0.5% are born with atypical genitalia, and 0.05% are born with full ambiguous genitalia.

Assigned sex

Intersex banner at trans march reading "Trans and intersex, migrants in social danger: expulsions, impoverishment, contamination, and violence." Existrans 2017, Paris.

The vast majority of intersex people with ambiguous genitalia are assigned female at birth, as it was generally thought that it was easier to create a girl then a boy. Likewise as puberty would result in general feminization for most intersex children as well as a low libido, it was thought that they should be assigned female. This was also motivated by the fact that vaginoplasty was far more developed than phalloplasty.

This system was known as the "optimum gender of rearing model" (OGR model) which attempted to define a binary for intersex children. Some individuals who did not have any intersex conditions were raised under the OGR model, such as David Reimer who suffered a botched circumcision and was assigned female at birth. The primary goal of the OGR was to stop gender incongruence, and to assign a gender binary for "proper" sex socialization. The model often specifically involved the falsification of medical history, such as the karyotype falsification or that internal testis were ovaries and needed to be removed for "cancer," despite no physical complications existing from their presence.

Intersex advocates used a feminist perspective for criticism of the OGR as inherently sexist and cruel. The OGR modeled girls as passive and the receivers of penetration, and boys as the givers of penetration. As most intersex conditions cause vaginal like development and no phallus medical staff were biased towards assigning female at birth. Transfemminists and those queer liberationists particularly criticized the OGR model for not allowing children deviate from gender binary or expression. Likewise feminists view bodily autonomy as a fundamental human right, which led to criticisms of the OGR taking away the bodily autonomy of intersex people.

Intersex and medical definitions

The Phall-O-Meter satirizes clinical assessments of appropriate clitoris and penis length at birth, and the definition of ambiguous genitalia. It is based on research published by Suzanne Kessler.

The OGR stated that gender non-conformity was a physiological threat which effected an individuals ability to function in normal society, most research has found this to be false and that the medical procedures practiced against intersex individuals generally leads to isolation, physiological stress and physical complications throughout life. The definition of intersex is closely linked to the specific medical interventions on intersex people, which was further expanded by feminist critique.

The DSD has generally superseded the OGR in the US, although no official medical precautions exist against intersex genital mutilation in the US. Another point of contention is intersex conditions and karyotype, while many intersex individuals have atypical gene expression, many intersex individuals are born due to hormonal changes in pregnancy, either natural or induced. As an example, a case of a woman who has a virilized clitoris which was surgically altered during birth, brought up the point that she was intersex, which was stated to be "false" by a doctor as her mother had gone on progesterone, instead of natural virilization. Generally those who have undergone the OGR model, or have ambiguous genitalia The DSD consortium was specifically made to remedy this, and was advocated for by intersex activists by including all differentiation in sexual development.

The definitions of intersex genitalia are difficult as different medical practices exist in different regions for what a "normal" penis or vagina should look like. Although 0.5% of births show atypical genital development, only 0.05% are considered for medicalization, and this varies by region.

Spectrum approach

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

Many intersex activists have advocated for a spectrum based approach for intersex conditions, which would differentiate various intersex conditions, including hormonal differences. Intersex conditions, even the same conditions such as ovotesticular syndrome, can vary wildly in terms of organs, genetic expression, phenotype, genotype, and karyotype. Under this model intersex conditions would be described via their own individualized effects described as effecting individuals on a spectrum. The DSD generally describes this by the description of individualized care for people with atypical sexual development, making the distinction between different conditions.