Not Everyone Is Male or Female – The Growing Controversy Over Sex Designation

Summary: Researchers say millions of people do not fit neatly into the sex designation assigned to them at birth, and a wrongful identification can set them up for a lifetime of mental health and physical challenges.

Source: The Conversation

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.

Credit: Them

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.

Credit: As/Is

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.

This shows a baby's feet with a daisy
Although the medical establishment is now recognizing that sex is not binary, society as a whole has been slow to embrace the concept. Image is in the public domain

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.

Funding: Carl Streed receives funding from the National Heart, Lung, and Blood Institute and the American Heart Association. He is affiliated with the US Professional Association for Transgender Health and the American Medical Association.

About this neuroscience research news

Author: Carl Streed Jr and Frances Grimstad
Source: The Conversation
Contact: Carl Streed Jr and Frances Grimstad – The Conversation
Image: The image is in the public domain

Join our Newsletter
I agree to have my personal information transferred to AWeber for Neuroscience Newsletter ( more information )
Sign up to receive our recent neuroscience headlines and summaries sent to your email once a day, totally free.
We hate spam and only use your email to contact you about newsletters. You can cancel your subscription any time.
  1. my stalker did once tell me “You were really asking for it” because I knew they have a foot fetish and I made the awful mistake of being barefoot. Funny how people say someone deserves to be raped then blames the person they plan on violating for their own behavior.

  2. I am disappointed that Neuroscience News would publish this article. It is based on biased unsupported information. To remove sexual designation from the vast majority of individuals would cause harm in many ways. The 1.7% statistic is taken from an archived website (Intersex Society of North America) that was trying to exaggerate the rate for political purposes. The true number of individuals with Disorders of Sex Development (DSD) is quite low. “When all congenital genital anomalies are considered, including cryptorchidism and hypospadias, the rate may be as high as 1:200 to 1:300.” Of these many will still have a valid binary designation. See this consensus report for a balanced discussion of all aspects.

    Lee P, A, Nordenström A, Houk C, P, Ahmed S, F, Auchus R, Baratz A, Baratz Dalke K, Liao L, -M, Lin-Su K, Looijenga 3rd L, H, J, Mazur T, Meyer-Bahlburg H, F, L, Mouriquand P, Quigley C, A, Sandberg D, E, Vilain E, Witchel S: Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care. Horm Res Paediatr 2016;85:158-180. doi: 10.1159/000442975

  3. Dr. Jim Robin argues that because there are more combinations and permutations of X and Y chromosomes than just two, we should consider eliminating the male/female identification box on birth certificates.

    I would argue that in a dualistic world, everything is either a or b, 1 or 0, yes or no … So we look at a newborn child’s genitalia and identify it as him or her, Jim or Joan. But the world is not really dualistic. It is more nuanced than that. But as Alanis Morisette sings: we don’t have it all figured out just yet. Throwing the baby out with the bath water would be just plain wrong. It would leave the vast majority of people who fit the dualistic model uncertain about their identify and just plain angry. The world is full of people of color. Not just black, white, yellow and brown, but hundreds of shades of those four colors. Should we invent hundreds of races based on the shade of color we are?

    But that is not really the dilemma. Our gender identification problem is not with the people in our world who do not fit the dualistic male or female model. It is with a small minority of people who identify as someone who has the other kind of genitalia and their supporters who want to force a political solution to a problem that is not political. The solution is not to erase everyone’s sexual identity. Creating chaos out of order is an abomination, not a solution. Nature is amazingly diverse. It is detailed. It is nuanced. It is ordered. It is not chaotic. The solution is in acceptance. We can learn to accept that there are animals in the world that change sexes during their life times. We can learn to accept that there are humans who may have variant combinations of X Y chromosomes or different variations of male and female genitalia. We can accept that some people will be happier living as if the other box on their birth certificate had been checked.

    Even the most accepting of societies, however, has to understand that the men and women of today are what they are because of how they were able to successfully evolve: males as the hunters and protectors and females as mothers and survivors. Those roles may no longer be appropriate in today’s few highly developed societies, but human development, unfortunately perhaps, has not kept pace with societal and technological development. Perhaps the world as a whole has just not developed sufficiently for our roles and sexes to become more fluid, more widely diverse. Until that happens, and it may be the next human species that does it, it is still necessary and appropriate to check male or female on a birth certificate even if it requires a written explanation. Removing male or female on a birth certificate would be no more helpful today than removing the race box. Maybe tomorrow.

  4. funny how there is never any question as to which SEX shall have it’s reproductive rights STRIPPED AWAY. & Funny too how SEX selective abortions only MURDER one particular sex. “”One condition that impacts only women and may contribute to continued ill-health is pregnancy and childbirth..maternal deaths and disabilities is a leading contributor to the burden of disease among women.” Pubmed. STOP THER BOLLOCKS!

  5. Ditching all preconceptions based on the abusive power politics of the minority is the complete antithesis to scientific discovery. Allowing the tyrannical application of those deviant from normal expression to define expression itself is poppycock and massively unwise. You know what is far far worse than some 4000 poor souls born wrong every year? Forcing tens of thousands and and far far more to be subject to hormone therapies and childhood indoctrination as a result of the singular fringe case in the community. It is disgusting and countless professionals will kill themselves when they realize the horror they have allowed.

  6. I do not subscribe to this newsletter to read pseudo scientific crap like this. Find me someone who is neither male nor female or has the ability to get themselves pregnant. Anyone making a living out of the trans industry should not be listened to as they are constantly pushing bilge like this trying to make out the “trans” people are some different type of human. They’re not.

  7. If ‘sex designation’is to retain any meaning, the term intersex should be restricted to those conditions in which chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype is not classifiable as either male or female. Applying this more precise definition, the true prevalence of intersex traits is seen to be about 0.018%, almost 100 times lower than 1.7%.

Comments are closed.