'Boy or girl?' tends to be the first question asked when a baby is born.

And a cursory look at the genitals usually provides the answer.

But it's not that simple, says Zachary I Nataf.

'Whatever I feel, that's the way I am. I was born a girl, and that girl died one day and a boy was born. And the boy was born from that girl in me. I am proud of who I am. A lot of people actually envy us.' Chi-Chi, who lives in a village in the Dominican Republic, is speaking to filmmaker Rolando Sanchez for his 1997 documentary Guevote.

The film portrays the daily lives of Chi-Chi and Bonny, two 'pseudo-hermaphrodites', and the way in which their families, partners and other villagers respond to them.

They are not alone. A rare form of pseudo-hermaphroditism was first found among a group of villagers in the Dominican Republic in the early 1970s. Thirty-eight people were traced with the condition, coming from 23 extended families and spanning four generations.

Chi-Chi's mother has ten children. Three of those ten are girls, three of them are boys 'and four are of this special sort.' she says. 'I knew that this sort of thing existed before I had my own kids. But I never thought that it would happen to me... I told them to accept their destiny, because God knows what he's doing. And I said that real men often achieve less than those who were born as girls. And that's how it turned out. My sons who are real men haven't achieved as much as the others.' 1

The medical explanation is that, while still in the womb, some male babies are unable to produce the testosterone which helps external male genitals to develop. They are born with a labia-like scrotum, a clitoris-like penis and undescended testes.

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In the Dominican Republic many of these children were first assumed to be female and were brought up as such. But because they were genetically male, they began to develop male characteristics at puberty, including penis growth and descending testes. Villagers gave these children the local name guevedoche or 'balls at twelve'.

For some scientists the phenomenon presented an ideal 'natural experiment' that would help them to prove once and for all that hormones are far more important than culture in the development of gender identity. A research team headed by Julliane Imperato-McGinley proposed that in a laissez-faire environment, with no medical or social intervention, the child would naturally develop a male gender identity at puberty, in spite of having been reared as female.2

Not everyone agreed with this rather simplistic approach, however. Ethno-grapher Gilbert Herdt pointed out the guevedoche were different and they knew it as they had compared their genitals with those of girls during public bathing. Villagers, who were familiar with the guevedoche over generations, accepted them as a 'third sex' category, sometimes referring to them as machi-embra (male-female).3

Furthermore, not all guevedoche wanted to adopt a male gender identity after puberty. In the documentary Guevote, Bonny relates the case of Lorenza. 'She had more chances as a woman. Lots of men fell in love with her. She always wore women's clothes and had very long hair. She liked it when men fell in love with her. That's why she wanted to stay a woman and not become a man.'

Here then is a community that recognizes the actual existence of 'third sex' people as part of human nature and creates corresponding gender roles to accommodate them. It's an attitude that enables Bonny to say: 'If I am like this, God will know why... If I feel good, why should I change things? This is how I grew up, why look for something else?'

The law and the knife

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Such an accepting approach to gender ambiguity has not been the pattern in most of the Western world. Far from it.

Since the routine practice of correcting the ambiguous genitalia of intersexed children began in the US and Europe in the late 1950s, debates have raged about whether gender identity and roles are biologically determined or culturally determined.

The work of John Money and colleagues at Johns Hopkins University and Hospital, Maryland, has had a major impact on the treatment of intersex children, transsexuals and other sex-variant people.

Money advised on the famous case of the identical twin boy who had been reassigned as a girl after he lost his penis in a circumcision accident at the age of seven months in 1963. The child underwent plastic surgery to make his genitals female-appearing and he was treated with female hormones at adolescence.

Between 1973 and 1975 Money reported a completely favourable outcome and this became the key case in the following 20 years. The case influenced the treatment of boys born with 'too small' penises, and led to the recommendation that their penises and testes be removed and the boys be surgically reassigned as girls before the age of three 'to grow up as complete a female as possible'. In these cases quality of life was based on ideas of adequate heterosexual penetration. According to the Johns Hopkins team, the twin had subsequently been 'lost to follow-up'.

But this was not so. As it turned out, the twin did not feel or act like a girl and had discarded prescribed oestrogen pills when aged 12. She had refused additional surgery to deepen the vagina that surgeons had constructed for her at 17 months, despite repeated attempts to convince her she would never find a partner unless she had surgery and lived as female. At the age of 14 the twin refused to return to Johns Hopkins and persuaded local physicians to provide a mastectomy, phalloplasty and male hormones. He now lives as an adult man.4

Intersexuals, popularly refer-red to as 'hermaphrodites', are usually born with genitals somewhere between male and female - rarely with two complete sets as in myth. The number of such births is more common than most people realize, with the highest estimates in the US at four per cent of births.5

According to the Intersex Society of North America one in every 2,000 infants is born with ambiguous genitalia from about two-dozen causes. There are more than 2,000 surgeries performed in the US each year aimed at surgically assigning a sex to these intersex patients. The Intersex Society campaigns against what it sees as the unethical medical practice of performing cosmetic surgery on infants who cannot give consent.

Doctors believe that quality of life is only possible for individuals who conform to male or female sex and gender. But the founder of the Intersex Society, Cheryl Chase, believes that 'most people would be better off with no surgery'. Born with ambiguous genitalia herself she was raised as a boy until 18-months-old when physicians told her family that she was really a girl and removed her enlarged clitoris. At the age of eight she underwent an operation to remove what she later learned was the testicular part of her ovo-testes. She currently lives as a woman and, like many intersex individuals, is lesbian. The surgical excision and scar tissue has left her without clitoral sensation or orgasmic response. Says Ms Chase: "Genital mutilation" is a phrase that's easy for us to apply to somebody who belongs to a Third World culture, but any mutilating practice that's delivered by licen-sed medical practitioners in our world has an aura of scientific credibility.' 6

Her experience is shared by many intersexuals who as children underwent repeated unexplained examinations, surgery, pain and infection. This has gone on for four decades and in most cases the children have been 'lost to follow-up'. This means there has been no reliable medical data to assess the effects of surgery or to provide guidance for future practice.

Cosmetic genital surgery is used to 'normalize' the appearance of ambiguous genitalia. It is admitted by surgeons to be an attempt to alleviate a 'psychosocial emergency' rather than a medical one. Instead of offering intersex children and their families or friends counselling to support them in accepting difference, doctors whip up a crisis which they can then fix with available medical technology. Ambiguous genitals are referred to as 'deformed' before surgery and 'corrected' after. But the reported experience of intersexuals who went through this in childhood is a sense of having been 'intact' before surgery and mutilated after it.

And children were often lied to. A typical example is recounted by a woman who, when her body began to change at the age of 12, was told that she needed surgery to remove her ovaries because she had cancer. What actually happened during the operation was her clitoris and newly descended testes were removed.

The adage that 'it is easier to dig a hole than build a pole' accounts for why most intersex individuals are made into girls. The standards which mark maleness allow penises as short as 2.5cm and femaleness allow clitorises only as large as 0.9 cm. Infants with appendages between 0.9 cm and 2.5 cm are, according to Suzanne Kessler, considered unacceptable and require surgical intervention. In some cases where parents haven't even noticed a problem doctors still insist on surgery. Baby girls as young as six weeks may be operated upon to deepen their vaginas, even though the surgery is not always successful and has to be repeated at various stages as they grow up.4

Some experts have their doubts. Dr Reiner, Assistant Professor of child and adolescent psychiatry at Johns Hopkins University warns against placing too great an emphasis on the genitals, pointing out that,'the brain is the most important sex organ in the body'. 7

Telling the difference

So how do we determine someone's sex? It's actually far more complex than most people imagine. There are no absolutes in nature, only statistical probabilities. We all begin life with a common anatomy which then differentiates if there is a Y chromosome present. This activates the production of testosterone, appropriate receptors in the brain and the formation of testes. The other features which do not develop remain in the body in vestigial form.

Several factors can be taken into account in determining a person's biological sex. They include chromosomal sex (X and Y, for example); hormonal sex (oestrogen and testosterone); gonadal sex (ovaries and testes); genital sex (vagina and penis, for example); reproductive sex (sperm- carrying and inseminating; gestating and lactating); and other associated internal organs (like the uterus or the prostate).

These factors are not always consistent with each other. In fact science admits everyone falls somewhere along a continuum. But few people would know if they were 100-per-cent male or 100-per-cent female, chromosomally or hormonally, as there are not many cases in everyday practice in which this would be tested. Unless you want to take part in the Olympic Games, that is, in which case you would have to undergo a chromosome sex test, although this has been abandoned as unfair and unreliable by other sports bodies. The British Journal of Sports Medicine claims that one in 500 female athletes and about one in 500 male athletes would fail the chromosome gender test. This is because chromosome variations do not necessarily affect physical appearance. A test might determine an athlete is not a woman for the sake of competition, but that certainly does not make her a man in her everyday life. Other indicators of sex are subject to similar variations. Even the capacity to reproduce is not a clear indicator: some intersex people have had children. The so-called biological line between male and female is frankly quite fuzzy.

So much for sex. But sex is not gender. Sex is biological. Gender is social, cultural, psychological and historical. It is used to describe people and their roles in society, the jobs they do and the way they dress, how they are meant to behave.

A person's gender is usually assigned at birth, with a cursory look at the genitals. The 'boy' or 'girl' which is documented on the birth certificate affects almost everything else that happens to that child socially for the rest of his or her life.

The third gender

Responses to ambiguous genitals vary from culture to culture. But in some societies that do not have access to surgery or whose world view is not mediated by biological 'facts' of science, there is more space for those who don't fit the norm. These children are accepted as a 'third sex' within the social order.

One of the most humane and enlightened approaches was observed in the 1930s among the Native American Navajo people. The Navajo recognized three physical categories: male, female and herma-phrodite or nadle. Nadles had a special status, specific tasks and clothing styles, and were often consulted for their wisdom and skills.



In India the hijra or 'third gender' caste

also attracts eunuchs, transvestites, homosexuals and transsexuals.

PHOTO: PETER BARKER / PANOS

In India the hijra have a 2,500-year-old history. Known contemporarily as a 'third gender' caste, hijra translates as herma-phrodite or eunuch or 'sacred erotic female-man'. They include intersex people, assigned both as male or female, but also attract to their community a wide range of transvestites, homosexual prostitutes and religious devotees of the Mother Goddess Bahuchara Mata.

Elsewhere, in the Eastern highlands of Papua New Guinea, third-sex people are known as kwolu-aatmwol or 'female thing transforming into male thing'. Medically they are like the guevedoche in the Dominican Republic. Although in some instances they may be killed at birth, most kwolu-aatmwol are accepted as such and are partially raised in the direction of masculinity. They retain some female elements to their unique identity but this does not prevent them from becoming respected shamans or war leaders.

In most parts of the world, however, powerful taboos operate, underpinning fear and discrimination. Sexually ambiguous bodies are threatening. Perhaps they elicit desire, possessing it might seem an erotic potential beyond those with ordinary genitals. Maybe the notion of sex or gender mutability provokes a kind of terror or gender vertigo.

Whatever the cause, medical professionals and others end up favouring drastic surgical remedies for minor conditions that present no medical or functional dangers.

But what about compassion and faith in the ability of the parents to cope with their own emotional pain and distress about their child's 'imperfection' and to nurture that child despite their difference? What about the rights of the child, especially the right of the child to decide their gender identity, if different from what the experts have designated it to be?

Challenging such rigidity is the Transgender Movement. This is a broad alliance of people who are inclined to cross the gender line. It includes cross-dressers and transvestites as well as intersex people and transsexuals - both those who have and have not had 'gender realignment' surgery.

Transsexuals whose gender identity is in conflict with their birth gender usually want to achieve a congruence of identity, role and anatomy by having sex-reassignment surgery. But increasingly transsexuals are taking the option to be 'out' as transsexual and are deciding against surgery, without compromising their core gender identity. It's simple. Some men don't have penises and have vaginas, some woman have penises and don't have vaginas.

The trend toward gender non-conform-ity is growing and has come about partly as a result of anger at discrimination, stigmatization, lack of civil rights and a reluctance on the part of the authorities to pursue those who commit hate crimes against non-conformists.

As a transgendered man (female to male transsexual) I do not 'pass' as simply male but am 'out' in order to campaign for non-discrimination and Transgender Pride. I did not choose to be transsexual, nor did I change gender roles in protest against society's oppressive gender system. I did it to achieve an authenticity and outward expression of a deeply abiding sense of myself as a gendered being. During transition I became more fully and truly myself, suspending the symbolic hold society's rules had over my body in order to achieve it. The rigidity of the rules is what is not natural.

There are specific struggles, such as trying to get legal recognition and legal rights in societies where one has to be either male or female. Attitudes are very fixed. In Britain, for example, even post-operative transsexuals are legally padlocked forever to the gender written on their birth certificates, even though this contravenes the European Charter on Human Rights. While in the US, gender non-conformists are still listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

But those who don't fit the rules are drawing encouragement from information about third-gender identities in other cultures. As this space expands, more transgender and intersex people are opting to live bi-gendered or hybrid gendered lives, choosing hermaphroditic bodies, through surgery, to match their core sense of who they are.

This expansion is not only an issue for intersex or transgender people. It liberates everyone from rigid and stereotypic ways of being masculine and feminine, mixing the best of all for everyone.

Perhaps it will help pave the way to greater gender equality - or better still, irrelevance.

Zachary I Nataf is a transgender activist, author of Lesbians Talk Transgender (Scarlet Press) and director of the International Transgender Film and Video Festival in London.



1 Guevote, Rolando Sanchez, Fama Film AG, Bern, Switzerland, 1997.

2 Julliane Imperato-McGinley et al, Androgens and the Evolution of Male Gender Identity Among Male Psuedo-Hermaphrodites, New England Journal of Medicine, No 300, 1979.

3 Gilbert Herdt, Third Sex, Third Gender, Zone Books, NY, 1994.

4 Bo Laurent, Hermaphrodites with Attitude Quarterly, Fall/Winter, 1995-96.

5 David Berreby, Biology will Defeat the Defense of Marriage Act, SLATE, Internet, 10 September 1996.

6 David Tuller, Intersexuals begins to Speak Out on Infant Genital Operations, San Francisco Chronicle, 21 June 1997.

7 Katherine Maurer, Clinical Psychiatry News, vol 25, No 7, July 1997.

8 Serena Nanda, Hijras: An Alternative Sex and Gender Role in India, in ed. Herdt Third Sex, Third Gender, op cit.