Vera Livchak/Moment via Getty Images
By Carl Streed and Frances Grimstad
Check out your birth certificate and surely you’ll see a designation for sex. When you were born, a doctor or clinician assigned you the “male” or “female” label based on a look at your genitalia. In the U.S., this has been standard practice for more than a century.
But sex designation is not as simple as a glance and then a check of one box or another. Instead, the overwhelming evidence shows that sex is not binary. To put it another way, the terms “male” and “female” don’t fully capture the complex biological, anatomical and chromosomal variations that occur in the human body.
That’s why calls are growing to remove sex designation from birth certificates, including a recent recommendation from the American Medical Association.
I am a professor of medicine who has worked extensively on lesbian, gay, bisexual, transgender, queer, intersex and asexual (LGBTQIA+) issues. My co-author is a professor of gynecology who is deeply involved in the health of people who are trans and intersex.
Our research and clinical experience show that sex designation is not something to take for granted. For those who don’t fit neatly into one of two categories – and there are millions – an inappropriate classification on a birth certificate can have consequences that last a lifetime.
The problems with sex designation
Variations in genital anatomy happen more frequently than you might think; they occur in 0.1 to 0.2% of births annually. In the U.S., that’s about 4,000 to 8,000 babies each year.
Other sex traits don’t necessarily help either. Doctors examining the reproductive organs can find people born with both a vagina and testes, and also those born without any gonads. And when evaluating an individual’s estrogen and testosterone hormone levels, long defined as key determinants of female and male bodies, doctors find some people with vaginas still produce significant amounts of testosterone. Because of this, testosterone is not a great indicator for defining sex; higher amounts of testosterone do not necessarily make someone male.
Even karyotyping – a laboratory procedure used since the 1950s to evaluate an individual’s number and type of chromosomes – doesn’t tell the whole story. While we typically expect people to either have XX or XY pairs of sex chromosomes, many people have variations that do not fit either category. These include Turner syndrome, in which a person is born with a single X chromosome, and Kleinfelter syndrome, which occurs when a person is born with a combination of XXY chromosomes.
In short, human diversity has demonstrated that the binary categories of male and female are incomplete and inaccurate. Sex designation, rather than “two sizes fit all,” is on a spectrum. Up to 1.7% of the U.S. population – that’s more than 5 million Americans – have an anatomy and physiology that present intersex traits.
Binary designations can be damaging
Those with intersex traits who are assigned at birth to be female or male can experience medical care that harms them, both physically and psychologically.
Sometimes physicians perform surgeries to align bodies into binary categories. For example, those born with a larger than typical clitoris may have it reduced in size. But some who have this childhood surgery suffer as adults from pain and difficulty having sex.
Additionally, governments sometimes limit those with intersex traits from fully participating in society. For instance, in Australia, marriages have been annulled because governments have previously ruled that an intersex person – someone not seen to be “100% man” or “100% woman” – cannot be legally married.
Private entities often do the same. The International Olympics Committee uses cutoffs of hormone levels to determine who plays in women’s sports. As a result, some athletes have been barred from participation.
And for those with a gender identity that differs from the sex designation on a government document, discrimination, harassment or violence can result.
State governments have begun to acknowledge sex diversity. Some let gender-diverse people change their designation on birth certificates, although there are restrictions. Medicine too is changing. For example, some pediatric centers have stopped performing surgeries on newborns with differences in sex development. Still, society at large has been much slower to move beyond the use of strictly binary categories.
As clinicians, we strive to be accurate. The evidence shows that using male and female as the only options on birth certificates is not consistent with scientific reality. Evidence shows that removing this designation will tell new parents that it’s not sex assignment that’s most important at birth but rather the celebration of a healthy and happy baby.
Carl Streed is Assistant Professor of Medicine at Boston University. Frances Grimstad is Assistant Professor of Gynecology at Harvard University.
The Conversation arose out of deep-seated concerns for the fading quality of our public discourse and recognition of the vital role that academic experts could play in the public arena. Information has always been essential to democracy. It’s a societal good, like clean water. But many now find it difficult to put their trust in the media and experts who have spent years researching a topic. Instead, they listen to those who have the loudest voices. Those uninformed views are amplified by social media networks that reward those who spark outrage instead of insight or thoughtful discussion. The Conversation seeks to be part of the solution to this problem, to raise up the voices of true experts and to make their knowledge available to everyone. The Conversation publishes nightly at 9 p.m. on FlaglerLive.
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Mark says
LOL! 6000 out of 350000 is not many!
Charlie says
This article makes me want to throw up and is a perfect example of what is wrong with the country thanks to liberal democrats.
Trust the science says the democrats. I will. Born with a penis you’re a man. Period.
Pierre Tristam says
Calm down Charlie, no one’s trying to take your toy. A little Pepto in your chromos might help.
Bill C says
Look at your chest Charlie- ever notice you have nipples there?
jake says
So I guess the 99.9% of us, are just wrong or unacceptable.
tina tinsley says
Right and we have to allow this mess when our kid comes home from school saying they them…trendy to want pronouns as hetero but to be accepted. Get over it. Nobody at work cares who I have sex with. Why do gay ppl deserve special privileges bc they openly discuss about sex and doing so with the same gender. Putting hetero gay etc…sexual preferences is not a good idea to get hired in my company. Who when where what u wanna bang tells me nothing about work. Sad generation if that’s all they got is sexuality.
Anonymous says
Your gender male or female is decided at conception. Follow the science Miss Pierre.
Deborah Coffey says
A very well presented article and easy to understand. Of course, the haters don’t believe in science or scientific evidence…they’re too busy wallowing in their hate in order to feel better about their own miserable lives.
As for the fake Christians who need constant reminding…the catechism I learned from had this as its first question and answer: Who made me? God made me. Maybe they should take that and run with it.
Geezer says
I am remembering my shopping experiences at the Middlesex Mall in NJ…
These days it’s called the Non-Binary Mall.
Yes, I’m old and tell corny jokes.
Sherry says
@ Charlie. . . did you even read the entire article? Why are you so angry and adamant? Being educated by science/medical expertise “should” not be a political issue. It sounds as if you are implying that Republicans should remain stubbornly illiterate. . . while those (damned?) Democrats blatantly continue to learn. Surely you realize that education. . . even continuous education of mature adults. . . is vital to an evolving society. Right Charlie?
@ Mark and Charlie . . . while there is a small percentage of completely innocent people that fall outside the definition of male or female, those who suffer the terrible life long resulting discrimination certainly deserve some attempt to make their lives more acceptable in society, right Mark and Charlie?
Charlie says
Been with both women and men. While I enjoy them both in different ways, it’s very obvious the difference between a man’s muscle hard body and a womens soft and supple squishy body. One other big difference too but there are some similarities even there. Maybe a trans would be the best of both worlds.
Mark says
The small percentage bron different are not the problem. It is the mentally ill people who decide they are something other than what they are that are the problem.
LetsBeReal says
Three genders. Male, Female, and Confused.
Merrill S Shapiro says
As for me, I’ll stick with the word of God as revealed in the Book of Genesis, Chapter 1, verse 27: “Male and female created he them!” Human beings were, and still are, neither male nor female but some combination of the two! This article has it right! “The evidence shows that using male and female as the only options on birth certificates is not consistent with scientific reality”
Sherry says
Geeeez Jake. . . where does this article say that 99% of people are wrong or unacceptable????
Are you so very entrenched in the notion of your own “I am all knowing and always right” self speak that scientific evidence can teach you nothing? The world is NOT “black and white, Jake. A scientific analysis does NOT exist to make anyone wrong. . . it is what it is. . . analysis and conclusion based on FACTS. . . NOT “popularity” . NO, scientific findings are not based on what people “choose” to believe. If you “feel” threatened by intellectual factual reasoning, perhaps you should reevaluate your basis for your perceptions of life/society/culture/politics/government and consider leading with your intelligence and education instead of your emotional responses created by what you are being fed by obviously right winged media outlets.
Just because FOX is popular does not make it the best source for credible factual information.
Eileen Araujo says
Lord help the future generations who will have this crap shoved down their throats. Talk about making it more confusing then it already is. Good luck “boys and girls”, you’re gonna need it.
Pierre Tristam says
Funny how the transphobic, the homophobic, the heretrosupremacist always, always resort to that metaphor of such and such being shoved down their throat when objecting to something that doesn’t concern them, doesn’t affect them, doesn’t change the lineup of their family pictures on their living room mantle, and when whatever they fear wouldn’t go anywhere near their throats even if they begged. The hetero doth protest too much, theythinks.
Jenn Smith says
Quite the controversial topic. Why stir up opinions from those who don’t agree with you only to have the stance to disagree and create division amongst your readers? Why is this even being shared to Flagler Live? Why not focus on the kids who were just murdered and the fact that children are running around with guns killing other children? Instead, the focus of the day is fishing for people (mostly from the generation X and older community) to disagree with modern ideas of how one should think or dare to have an opinion that doesn’t suit your own about accepting a new modern approach of accepting a specific group, groups or way of thinking? It is clear that the ones who may not agree aren’t stirring discussion, are probably just confused, or could care less. I wouldn’t think any of the “homophobic” could give two shits about a discussion regarding if we are boys or girls, but more so the fact that our boys and girls are unsafe amongst whatever these soulless boy/or girl monsters are that are running around with guns killing people.
Unite, not divide the community.
Pierre Tristam says
It’s not journalism’s job to unite or divide communities. Outlets that do are not conducting journalism but propaganda. It’s our job to report and carry quality opinions and debates, among other things. You’re free to comment, but other commenters will hold you accountable for what you say. All opinions may be created equally, but won’t necessarily be treated equally: some aren’t worth the airs they’re made of, and a few can be very interesting. If you’ve followed this site, or even this specific spot (The Conversation) you’d have noticed numerous pieces on guns.
Mark says
Actually it is not the hetero that protest too much.
Sherry says
@Eileen. . . perhaps you should take a moment for some introspection to examine why in the world scientific analysis evokes such an emotionally angry response from you. Is it time to “unplug” and find your intellectual power and reasoning ability again? In any case, wishing you the strength to find the path to educated, open minded acceptance of others. . . and, of course to internal peace.
To be determined says
Funny how anyone that disagrees with this article is immediately referred to as Homophobic, blah, blah. Yes, there are babies born with both genitalia, which would be very hard to deal with for any parent and in those situations, only they and their child can make that decision as to what sex they want to be or feel more inclined, but to say that any baby born should not be identified as a sex for a minority of people is crazy. Take any boy and remake him into a girl and he will naturally be stronger. Yes, sometimes it can be disguised, but if you study people its easy to detect femininity, no matter how much you try to change your looks, voice, etc. Plus I know people that have gone through the actual revisions and it didn’t bring them the happiness they thought they would have. Anyway, point being, this is parents to decide. Talk about a confusing time children are living in right now when they don’t even know what to call their baby brother or sister..
joe stolfi says
herewegoagain .
Concerned Citizen says
I’ll make this simple. And this is from about as a “Good Ol Southern Boy” as they come.
I Don’t care if you are black brown white or any color. As long as you respect people and treat people decent. I don’t care if you have a penis and think you want a vagina. Or you have a vagina and want a penis. As long as you are repsectful and treat people. decent. I don’t care if you worship God or Allah as long as you respect people and treat people decent.
Speaking for myself I allow people in my life regardless of whom or what they might think they are. As long as they aren’t asshats. Once you show those colors it’s adios. Because life is short and I have zero time for foolishness. My wife is the same way. Regardless of the troubles we have faced an an inter-racial couple. We give everyone an equal chance to be in our lives.
Society spends way to much time labling and hating on each other. Time to grow up. I’ve lost so many loved ones over the years including both my parents that I have relaized time is precious and short on this planet.
If we stopped the hate and judging. And all the divsion imagine how much better this world would be?
Brad says
This is an excellent article that explains how gender is a social construct. The idea that people should be categorized in a binary fashion simply goes against human biology and its variants. Everyone needs, and should have, the freedom to identify as they know themselves to be regarding their gender identity and sexual preference, and they should be respected as such. I am an Indigenous Native American, and our tribal cultures have always recognized and honored at least three gender identities, some tribes as many as six. This is not a “problem” nor is it an aberration. Hatred, prejudice and persecution are the problems and aberrations. Think of how much of a better place the world would be if we did not have those.
Whathehck? says
Well said Brad and Sherri.new
This article reveals how some people are so set fast in status quo that fear of new knowledge drives them to be mean and insulting.
I am known as a hetero, a girl, then a woman. I wouldn’t care if I was known as a human pure and simple.
And let’s get rid of race on questionnaires. Should I be known as 100% white while my cousin should be known as part black part white. So what is she white or black or brown? Who cares what race we both are, we are both humans in a great family.
Enough with labels.