An Amish couple walks into a hospital, only there’s no joke here. This could be the hook to a story Dr. Tracy Bekx, a pediatric endocrinologist at the University of Wisconsin, Madison, told me. Having safely given birth with a midwife on their farm in rural western Wisconsin, the family she was called in to attend found themselves in a thoroughly modern setting — with an ancient predicament.

Their newborn had a noticeably large clitoris, a tell-tale sign of congenital adrenal hyperplasia (CAH) — the most common of the conditions grouped together under the term intersex or disorders of sexual development (DSD).

Historically, and still today in many places, the solution to these conditions is surgery; this implies, of course, that there is a problem. In fact, the variable terminology named above stems from this very issue — is intersexuality an identity or a disorder?

Removal of some flesh would make this little girl look the prescribed ways we’ve determined she should. All her chromosomal, hormonal, physical — and eventually behavioral — traits would tell a single story.  It’s a tale many have been asked to tell, even when they don’t believe it.

However, she was being seen in Madison where Dr. Bekx and her colleague Dr. Aaron Carrel help ensure that the tendency is to hold off on surgery unless it’s medically necessary. In large part thanks to the activism by and on behalf of people with intersex conditions–many of whom have testified to dissatisfaction with their surgically altered bodies–momentum is gaining toward waiting till the child can express its gender identity.  However, Dr. Carrel reports this practice is far from universal; as “the parents sometimes feel great relief that things ‘look normal’.” 

Even when nature doesn’t supply it, we’re content to invent, reify and enforce a standard.

The Way God Made Them

Gender expression occurs across a spectrum. For all our pink-wearing, doll-loving princesses, we find tree-climbing, car-collecting “tom-boys” — or kids who shift easily between these as the mood, toys and company inspire them. This range of gender expression is certainly not as wide for boys. However, as more men (and boys) embrace traditionally feminine pursuits, we will see the bandwidth of what’s acceptable include more frequencies.

But what about sex? How many sexes are there in humans? Is it quite obvious or subject to interpretation? Perhaps sex, like gender, is simply a man-made convention, upheld more by social norms than biological “fact.”

By gender I mean our presentation in the world. The roles we choose, or are required to play; the clothes we wear and the preferences we demonstrate. Gender can be understood as the coupling of two more concrete notions: gender roles and gender identity. For some lucky people, these two are a natural match — for others the disparity between them causes great difficulty.

Gender roles are perhaps most familiar to us. This is “father knows best” and mother having dinner on the table. It’s a set of social conventions that tell women to behave in certain ways and men in others. Gender identity, on the other hand, is what an individual feels compelled to do — the roles he or she (or none of the above) elects to play in any given interaction.

Gender identity can be fluid. Gender roles shift more like tectonic plates. Drifting imperceptibly over time, these seemingly fixed foundations can then accelerate and collide, shake and demand our attention. The legalization of abortion was just such a quake. It challenged our assumptions about what women “are,” how they differ from men, and what they’re put on earth to do. Some people are still jolted by the impact of this event and feel the earth is a shaky and unstable place ever since.

Notions of how gender ought to manifest — especially in instances where gender identity and presumed roles are in conflict, arise from biological determinism. This is the “because that’s the way God made them” line of reasoning. That is, there are fixed recognizable differences in the look and function of sex organs, presence of hormones and type of chromosomes that generate two distinct and bounded categories: male and female. And therefore man and woman.

But actually, there aren’t.

To paraphrase Judith Butler, gender is generally considered what bodies do, while sex is what bodies are. While medical science and social beliefs might contend that humans take exactly two forms, actual bodies defy these conventions.

These differences in human development, sometimes detected at birth, sometimes remaining hidden till autopsy, occur in such a vast array it’s hard for medical science to generalize about them. However, while their effects on genes, bodily appearance, sexual function, and hormones vary — they all call into question our untested truths about sex. And, by extension, any strict biological basis for gender.

Feminist theorists Kessler and McKenna contend “while gender can be seen as a social accomplishment, cross-cultural studies render gender as problematic as they highlight how it is usually regarded as a fact, when it can be shown to be constructed in different ways…what we ‘know’ about gender is grounded in the ‘everyday social construction of a world of two genders,’ where gender attribution seems more important than gender differentiation.”

Sex attribution, and gender along with it, is vitally important to us. Consider, as evidence, the first thing that’s announced about a new baby. Whether during ultrasound or at birth, the proclamation “it’s a _______” is the stuff of streamers, cigars and obsessions. Even before people declare the baby is healthy, they will tell you his or her sex. Because you’ve probably already asked them.

In most cases this is greeted with joy. A certainty that this spoken sex is correct, means something absolute, can be easily recognized and labeled. Even for those who don’t consciously believe sex comes with the guarantee of certain behaviors and preferences. When my husband said “it’s a boy!” it never occurred to me to respond “how do you know?”

But…how do we know? Determination of sex, as notable in cases where it’s anything but obvious, has shifted over time. Where once reading the subtleties of even the most unusual sex organs was taken as proof of one sex or another, now our knowledge of the body has complicated things. Today, it’s a dizzying combination of appearance, sexual function, hormones and chromosomes that help physicians and families assign a sex.

If gender is “social accomplishment” and sex an “assignment” you’re given at birth, this tells us something about how behavior becomes codified as biological truth. Never mind that behavior is often required and enforced by outside authority.

In many ways being of one sex — and therefore in our world, gender — or another is very much an assignment. A set of tasks to be completed in a specified way, a separation of yourself from other possible, also fixed, groups as in “assigned to the green team, not the orange one.” Or, more likely, to the pink team and not the blue. You play your part, hand in your work on time and wear the right uniform. Or you can wreak havoc on the system — refuse to stay on your side and turn in creative writing when you were supposed to do arithmetic.

Our vision of sex is so dichotomous, even things that appear gray are whited out or darkened over. People with ambiguous genitalia are still sent home with M or F typed next to the inked imprints of their tiny feet.

We’ve constructed a social reality with two and only two ways of being. Remember the Saturday Night live sketch about Pat, the person no one could identify as male or female? Even when we’re not able to pick one, we assume there are exactly two options possible.

Creating Categories

This need for clear categories goes well beyond sex. It’s a basic facet of human cognition. Cognitive linguist Eve Sweetser has written extensively about categorization as a tool of making sense of the world. In our interview, noted historian, author and former Intersex Society of North America (ISNA) board member, Dr. Alice Dreger echoed this saying “it seems like it was an evolutionary advantage to be able to categorize things. Things hostile to self and not hostile.” Thus, she maintains, the aversion to atypical bodies is based out of fear.

Sweetser has written, “categories can overlap and/or include each other: boundaries don’t need to be exclusive. Something can be blue and red at once (in fact, that’s what purple is, a combination of visual response in the red and blue neural patterns). This is an area where humans often seem to be particularly persistent in denial, though. If something is a member of one category, people don’t like to call it simultaneously a member of another contrasting category.” And, in the case of sex, they don’t like to admit the possibility that there are more than two categories or, worse yet, that the category concept need not always apply.

We believe the natural world exists, independent of us and our perceptions of it. Therefore, we need our current categories for sex to be a provable reality, not a man-made and therefore alterable convention. And if this requires having “facts” reinforce our constructed norms, it’s easy enough to make science comply.

In fact, Katrina Karkazis reports in Fixing Sex, it wasn’t until the 18th century that the notion of exactly two biological sexes emerged. Only then, for example, did differing labels emerge for sex organs in men and women. This shift was prompted not, as you might expect, through new scientific discoveries but through sociopolitical and economic changes. Culture dictated there be two and only two sexes. Male-dominated medical science readily complied.

Challenging the Sex and Gender Binary

As a set, DSD are actually quite common according to ISNA and the Endocrine Society but nevertheless not well known or understood. Granted, many can take such a mild form that the people who have them can go through life without knowing it. Although rare cases involve actual medical problems that require intervention, such as difficulty urinating, often there is no somatic distress and yet the discomfort and desire to “treat” remains.

The need to fix, and therefore pathologize, these physical differences emerge principally from our anxieties about gender. Thea Hillman, author of the lyrical Intersex (For Lack of a Better Word), believes it is our difficulty with our own identities that generates our discomfort with others who refuse to play their gender role. People figure out who they are by setting themselves in opposition to who they aren’t. If there’s more than two possible modes of being and you sum yourself up against the other, understanding yourself becomes more complex.

Dreger further points out that even the groups disadvantaged by our socially constructed boundaries derive benefit from perpetuating these divisions. In most sports, women are able to medal in the Olympics only because they are separated from men. A night out with your girlfriends or poker with the guys wouldn’t be much fun if men and women weren’t deemed distinct and divisible.

If we truly accepted everyone regardless of their genitalia or gender identity — how would we pick who should go out for the bachelorette bash or head to the stag party? Would we ask each person to choose or would we abolish these rituals?

There is undeniably a strong correlation between sex and gender, between a biological (chromosomal and hormonal) reality and the way a person acts and wants to be perceived. And there’s a case to be made for a causative relation here too.

However, this correlation is not absolute. Shades of differences in physical sex, gender identity, sexual orientation — not to mention shifts in these over a lifetime — attest to this.

It’s too long been standard practice to enforce a one-to-one relationship, to dismiss any divergence between sex, gender identity and even sexual orientation as some kind of problematic aberration. In fact, deviation from the mean is an interesting, useful and common aspect of humans in our forms and functions.

Individuals with ambiguous genitalia are a living reminder that sex can’t always be fit neatly into checkable boxes. Hopefully, as awareness and acceptance of intersex conditions grows, they will prove an effective challenge to our tired notions that sex is binary and determines gender. Perhaps then we will stop using our scalpels, conventions, and regulations to make this so.