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A human baby is born male, female and intersex. Wait, what???
We do not realize the privilege we enjoy for being born with the set of body parts that are considered normal. If you do not fit the bill, you will be discriminated not just by an average person but by doctors too even though Code of Ethics is taught in medical schools but maybe how to see a patient as a person first should be taught. Not everything needs fixing.
There are six viable combinations of our chromosomes X and Y, which means the person can also be born with combinations other than your average XX and XY. Addition or subtraction of an extra chromosome may present as a variation in the body parts they are born with or different levels of hormones. So, a girl may be born with testes instead of ovaries, and a boy may have a uterus.
Sometimes, a receptor for a chemical may either be present in a decreased amount or entirely absent, and sometimes a life-threatening condition may be present that needs immediate attention. Such variations in body parts and hormones are differences of sexual differentiation (DSDs). Every case is unique and every case should be managed according to their respective body needs. These individuals are referred to as Intersex as they fall somewhere on the spectrum of biological sex. All intersex are not transgender and all transgender are not intersex.
In the 1950s in the US, because of a mishap, a boy had to go through sex reassignment surgery advised by his then psychologist, Mr. John Money. That child was given psychotherapy to be raised as a girl for over 20 years, since back then psychotherapy was not unethical. For those 20 years “normalizing surgeries” became a norm where pediatric surgeons would attempt to “fix” an infant’s genitals to appear “normal”. There was no precedence and no research was done on the impact of such surgeries on the intersex individuals.
Some of these children who started to express their gender identity, could not align themselves with the sex labeled at birth. Despite psychotherapy, they faced mental health issues and wanted to transition. As they grew older, they became more vocal about the impact of those surgeries and condemned such practice. Irreversible surgeries done on infants or children who are unable to understand the pros and cons of any procedure and are not able to give informed consent are considered human rights violation.
It is important to know that the woman born with tests still needs them to produce hormones and must not be removed just for cosmetic reasons. Most of the time, it is told that there is a <5% chance for those testes to develop cancer and parent’s consent to their surgical removal in infancy, subjecting that child to lifelong hormone therapy. There are ethical concerns about such practice as we do not remove breasts of females born into a family with the history of breast cancer. One can question whether this surgery benefits the child or the surgeon and the pharmaceutical industry.
DSDs are taught as diseases and pediatric surgeons practice irreversible surgeries on infants without follow up researches justifying those surgeries. For most of the intersex children, gender identity is not a problem as most of them relate to themselves as males and females. But parent’s counseling is not done, and surgeries are usually never spoken about.
Adolescents start facing issues when they get distressed because of unusual scars on or around genitals, lack of sensation in the genital area, or some postoperative complication. They can also get distressed if their given label of girl or boy for rearing, does not match their expressed or experienced identity. An endocrinologist usually deals with them when their hormones kick in at puberty. For a few, secondary sexual characters bring in more distress. Their health concerns should be dealt by a multidisciplinary team of physician, pediatrician, psychologist, psychiatrist, geneticist, pediatric surgeon, and an endocrinologist.
We need intersex educators who can explain to others about the normal variation in human biology so the current situation gets destigmatized and they are not judged by the conditions they are born with. In Pakistan, the most common cases of Intersex are Congenital Adrenal Hyperplasia in XX individuals and Androgen Insensitivity Syndrome in XY individuals. Hypospadias is also a frequent occurrence but most urologists insist it is not an intersex condition, although all Intersex Organizations abroad confirm it is.
Pakistan does not register intersex on birth certificates and the sex for rearing is decided by the doctors and parents keeping in mind their psychosocial trauma. Globally there is a campaign going on against intersex genital mutilation. Pediatric surgeons are being asked to delay such surgeries till the individual is able to give informed consent. Health care providers must get these updates via Continued Medical Education or workshops so they can stop unethical practices.