In 1629, the General Court of Colonial Virginia met to decide if a certain settler was male or female. The settler in question had been born in England as Thomasine Hall, migrated to Virginia as an indentured servant named Thomas and continued to live in the colonies as both a man and a woman. After a forced bodily examination, the court still couldn’t decide Hall’s sex. So it ruled that Hall must always wear men and women’s clothing simultaneously.

It’s not clear why the court thought Hall’s body was ambiguous, but modern scholars believe Hall—who identified as “both man and woeman” in court—may have been intersex. An estimated one to two percent of the population is “intersex,” meaning they have both male and female sex characteristics.

The court’s ruling wasn’t an acceptance of Hall’s identity, says Elizabeth Reis, a professor of gender and bioethics at the Macaulay Honors College at the City University of New York and author of Bodies in Doubt: An American History of Intersex. Far from it: It was meant to punish Hall for “living part of the time as male and part of the time as female.”

The ruling may have also been a way of ensuring Hall wouldn’t “deceive” people about their sex. (This article uses “they/them” pronouns for Hall). Hall’s “punishment was such that they wouldn’t be able to do that anymore if they stayed in Virginia,” Reis says. Although most intersex people lived as one gender without switching back and forth, “the potential that intersex people might have of ‘fooling’ or ‘deceiving’ other people is kind of a theme that runs throughout American history.”

Olympic gold medalist runner Stanisława Walasiewicz, who went by Stella Walsh. Bettmann Archive/Getty Images

Over the next 400 years, official responses to intersex people would become much more medicalized, both in the U.S. and internationally. “Mandatory sex tests” for women (but not men) have been a part of international athletic competitions since at least 1950. The tests have barred athletes like Olympic gold medalist Caster Semenya from competitions, and retroactively stigmatized the achievements of athletes like Polish-American runner Stanisława Walasiewicz, whose two Olympic gold medals in the 1930s were questioned after a 1980 autopsy revealed she was intersex.

Although Hall seemed aware of their male and female traits, not all intersex people in history necessarily understood themselves this way. Take Casimir Pulaski, a hero of the American Revolution. Archaeologists recently discovered Pulaski may have been intersex because he had enough testosterone to grow a beard and also had a female-shaped pelvis. If his only female traits were internal, Pulaski may have lived his whole life without realizing there was anything “different” about him. Or, Pulaski may have noticed an unexpected change or lack of change around puberty but been unable to account for it.

READ MORE: Casimir Pulaski, General in the American Revolution, May Have Been Intersex

Revolutionary War hero Casimir Pulaski. Bettmann Archive/Getty Images

In a few cases, we know about historical people who may have been intersex because their spouse questioned their sex to “prove that the marriage couldn’t be consummated,” Reis says. “There was a case in the 1740s where a husband wanted to annul a marriage and the doctors inspected the wife’s body. The court refused the annulment, saying that her situation was operable” (it’s unclear what the operation would’ve been in this pre-anesthesia period, let alone whether the woman wanted it).

However, most historical records of intersex Americans come from the doctors who examined them. In the early to mid-19th century, doctors began to record and discuss encounters with intersex people in medical journals. One of these people was Levi Suydam, a 23-year-old white man and property owner in Connecticut who tried to register to vote in 1843. When someone challenged Suydam’s application on the grounds that he was more female than male and therefore couldn’t vote, a doctor from Hartford named William James Barry stepped in to examine him.

Based on the presence of some male sex organs, Barry decided Suydam was “a male citizen, and consequently entitled to all the privileges of a freeman,” as he wrote in The New York Journal of Medicine. That spring, Suydam was able to cast the deciding vote for the Whig party in a local election. Yet afterwards, Barry wondered whether he’d been wrong. He and another doctor found out Suydam menstruated and lacked facial hair. They also realized Suydam was sexually attracted to men, a characteristic the doctors considered inherently female.

Barry didn’t record how his follow-up examinations affected Suydam, so we don’t know if he ended up losing his right to vote. Still, the case illustrates some of the social anxieties bound up in identifying whether a person was male or female. If women and men had separate political rights and social roles, it was considered important for 19th century doctors be able to tell them apart.

“What these doctors starting in the 19th century really wanted to do was to make sure that people lived as one thing, one gender,” Reis says. “They would never have given Thomas/Thomasine Hall that punishment of wearing both [genders'] clothes.”

Toward the end of the century, doctors became especially anxious about the possibility of intersex people being sexually attracted to the same gender they identified with. “They were really trying to promote heterosexuality and also promote marriage,” Reis says.

As more women began to have their babies in hospitals, doctors started to perform these “corrective” surgeries in infancy rather than waiting until late adolescence or adulthood. H. Armstrong Roberts/ClassicStock/Getty Images

As medical science advanced into the early 20th century, doctors increasingly sought to “fix” intersex people through surgical interventions, some of which were necessary, while most were strictly cosmetic. They often wrote in their medical reports that after the surgery, the intersex person entered into a happy heterosexual marriage. Reis says we should be suspicious of these tidy endings, as doctors made ad hoc decisions about whether a person should live as a man or a woman and rarely considered the patient’s personal preference.

Whether a patient agreed to these surgeries was also irrelevant. In 1933, one article in a medical journal recounted a surgery to lower a young man’s undescended left testicle. When the physicians opened him up, they discovered he had a uterus. The doctors “voted” that the patient was therefore more female than male, and opened his scrotal sac expecting to find an ovary. Instead, they found a testicle. As the young man’s body lay open, the surgeons “voted” again, decided that he was more male than female and removed any female organs—all without his knowledge or consent.

As more women began to have their babies in hospitals instead of at home, doctors started to perform medically unnecessary “corrective” surgeries on intersex infants rather than waiting until late adolescence or adulthood, when a person might object. These types of surgeries peaked in the 1950s, with some doctors continuing to operate on intersex patients as they grew up, and continue today. “These surgeries serve primarily social rather than medical goals,” Reis notes.

We can’t know how surgery would’ve changed Hall’s life had they been subjected to it as a baby in Britain, but it's now clear that forced “corrective” gender surgeries can cause physical and psychological damage. “Every time you’re cutting into healthy tissue it creates scarring, and whenever there’s scarring it greatly increases risk of complications,” says Kimberly Zieselman, the executive director of interACT: Advocates for Intersex Youth and an intersex person herself.

Throughout history, intersex people or their parents often resisted doctors’ attempts to change their bodies for non-medical reasons, and continue to push back today. Two-time Olympic champion Caster Semenya has gone to court multiple times to fight orders by track and field’s governing body that she undergo hormone therapy to block her body's naturally high levels of testosterone, before competing in her signature event, the 800-meter women's race.

Intersex activists have called on states to ban infant surgeries that aren’t medically necessary for the roughly one in 2,000 babies whose bodies reveal intersex characteristics, and in 2020, California will be the first state to consider such a ban. It is already one of several states that issues “non-binary” birth certificates.

READ MORE: The Extraordinary Secret Life of Dr. James Barry