by Check your birth certificate and you will almost certainly see a sex designation. When you were born, a doctor or clinician assigned you the label “male” or “female” based on an observation of your genitalia. In the United States, this has been standard practice for over a century.
But naming sex isn’t as simple as looking at it and then checking one box or another. Instead, the overwhelming evidence shows that sex is not binary. To put it another way, the terms “male” and “female” do not fully capture the complex biological, anatomical and chromosomal differences that occur in the human body.
That’s why there are growing calls 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 very involved in the health of transgender and intersex people.
Our research and clinical experience show that gender designation is not something to take for granted. For those who don’t fit neatly into one of two categories – and there are millions – misclassification on a birth certificate can have lifelong consequences.
The problems with sex designation
Variations in genital anatomy occur more often than you might think; they occur in 0.1 to 0.2% of births each year. In the United States, that’s about 4,000 to 8,000 children each year.
Other sex characteristics don’t necessarily help either. Doctors who examine the reproductive organs can find people born with both a vagina and testicles, and those born without gonads. And when assessing an individual’s levels of estrogen and testosterone hormones, which have long been defined as the main determinants of female and male bodies, doctors find that 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 a man male.
Even karyotyping – a laboratory procedure used since the 1950s to assess an individual’s number and type of chromosomes – does not tell the whole story. Although we generally expect people to have either an XX or an XY pair of sex chromosomes, many people have variations that do not fit into either category. These include Turner syndrome, in which a person is born with only one X chromosome, and Kleinfelter syndrome, which occurs when a person is born with a combination of XXY chromosomes.
In short, human diversity has shown that the binary categories of male and female are incomplete and inaccurate. Gender designation, rather than “two sizes fits all,” is on a spectrum. Up to 1.7% of the US population – that’s more than 5 million Americans – have anatomy and physiology that presents intersex characteristics.
Binary designations can be harmful
Those with intersex characteristics who are assigned female or male at birth can experience medical care that harms them, both physically and psychologically.
Physicians sometimes perform surgeries to align bodies into binary categories. For example, people born with clitoris may be smaller than normal. But some people who have this childhood surgery suffer from pain and difficulty having sex.
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In addition, governments sometimes restrict those with intersex characteristics from fully participating in society. For example, in Australia, marriages have been annulled because previous governments have ruled that an intersex person – someone who does not see themselves as “100% man” or “100% woman” – cannot legally marry.
Private entities often do the same. The International Olympic Games Committee uses drops in hormone levels to determine who plays in women’s sports. As a result, some athletes were banned from participation.
And for those with a gender identity that differs from the sex designation on a government document, it can lead to discrimination, harassment or violence.
State governments have begun to recognize gender diversity. Some allow people of different genders to change their designation on birth certificates, although there are restrictions. Medicine is also changing. For example, some pediatric centers have stopped performing surgeries on newborns with differences in sexual development. Still, society in general has been much slower to move beyond the use of strict 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 new parents will be told to remove this designation that the most important sex assignment at birth is not a celebration of a healthy and happy baby.
This article is republished from The Conversation, a non-profit, independent news organization that brings you reliable facts and analysis to help you make sense of our complex world. Like this article? Subscribe to our weekly newsletter.
It was written by Carl Streed Jr, Boston University and Frances Grimstad, Harvard University.
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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.
Frances Grimstad does not work for, consult with, own shares or receive funding from any company or organization that would benefit from this article, and does not she has disclosed any relevant connections beyond her academic appointment.
