Babies who are born genetic males but lack sensitivity to male hormones are sometimes born with ambiguous genitalia, and often the decision is made to raise them as female because treatment with female hormones is considered more successful. A surgeon shapes the genitalia into female sex organs.
At Johns Hopkins Hospital, they have a "gender committee" that meets whenever an intersex baby is born. The team is headed by a pediatric endrocrinologist, but also contains a surgeon, a social worker and a clergyman among others. Together with the parents the team evaluates the baby and decides upon the best course of action.
What is "best," of course, is still under debate, but Gearhart hopes the increased attention to the issue of sexual identity will help future kids caught in the middle. "These long-term studies provide better science for the younger generation," he says.
Intersex Group Calls Surgery 'Mutilation'
Not all those born with ambiguous genitalia are happy about surgery that alters their sex. An organization called Intersex Society of North America, or ISNA, is devoted to educating people about intersex individuals, and they are challenging the way doctors treat intersex babies.
The group contends surgery can damage a person's sexual function for life. The patient may lose feeling in his or her genitals and be unable to have normal sexual relations. Some intersex individuals even call the surgery "mutilation."
ISNA recommends letting the patient decide whether or not to have surgery, which means waiting until a child is old enough to make such a complicated decision.
But many physicians believe it would be more harmful to wait, and worry about the impact of growing up intersex in a world unprepared to deal with such variety. "I've had parents say, 'I can't stand changing the diaper,' " Peters says.
But ISNA argues it is society's job to adjust to intersex individuals and recommends counseling for families and patients dealing with the issue.
While Gearhart praises ISNA for raising awareness about intersex issues and pushing doctors to rethink their positions, he adds, "Initial studies from Hopkins are finding that most intersex people don't support the idea of a third gender."
Notes Peters, "A lot of the adults complaining about the surgery is based on old technology. We didn't know as much then, and surgeons would do things like cut away the entire clitoris. Surgery has improved a lot over 20 years ago."
But some surgeons find merit in ISNA's message.
"It's rare that an enlarged clitoris would cause any medical problems, so we have time to wait," says David Vandersteen, pediatric urologic surgeon and vice-chief of surgery at Children's Hospitals and Clinics of Minneapolis/St. Paul. "[Gearhart's study] suggests that the relationship between external genitalia and psycho-social development is moderate at best, and shows there is good psychological foundation for leaving well enough alone."
Another point of debate is what and when an intersex child should be told about his or her medical history. In Gearhart's study, the children and young adults still living as females have not been told about their male genetic status.
ISNA favors telling kids as much as they can digest while they are still very young. Doctors are less sure about the timetable.
"A lot of bitter adults are bitter because they were never told," Peters says. "I believe kids should know but I don't know when. Finding out this information as a teenager would be difficult."