What is hermaphrodism and is it something that should be 'treated'?
A hermaphrodite (or intersexed person) is someone who has some or all of the primary sex characteristics of both genders (for example, a penis and a vulva). There are three types of hermaphrodites: true, male pseudo and female pseudo.
A true hermaphrodite is someone who has both ovary and testicular tissue. The genitalia can vary from completely male or female, to a combination of both or even ambiguous looking. Female pseudo means that a person has XX chromosomes with normal female internal organs but with masculanised genitalia, while male psuedo means that person is born with XY chromosomes. Such a person has testes which are usually hidden in the abdominal cavity. The external genitalia are usually female.
The situation in South Africa
In South Africa, as in the rest of the world, hermaphrodite babies are not unusual.
The first two questions parents ask when their baby is born, are '"'Is it a girl or boy?' and 'Is everything OK?' In the case of hermaphrodite babies, both questions are difficult to answer, even though these babies are usually perfectly healthy in all other respects," says Dr Philip Henning, a paediatrician at the Tygerberg Hospital in Cape Town.
“There is a fair amount of societal pressure on parents and doctors to make a decision one way or another. When surgery or hormonal treatment is considered, many factors are taken into account. The dominant sex of the baby is determined using many tests, including chromosome tests, urine tests and ultrasound to determine the internal genitalia of the baby.
"The baby’s appearance is considered, and all factors are considered before this life-changing decision gets made. In many cases, hormonal treatment is sufficient and no surgery is needed,” Henning added.
Many hermaphrodite babies have an extra sex chromosome, making them babies with 47 chromosomes instead of 46, including a XXY pair instead of either XX (female), or XY (male). These children thus have two X-chromosomes (like a normal female), as well as a XY-pair (like a normal male). With a Y-chromosome present, the babies have testes and will produce testosterone, with the likelihood of a male orientation.
The possibilities of modern surgery
There always have been such babies, but it wasn't until the post-World War II years that the American medical community developed the skills and tools to surgically correct genital abnormalities. Surgery soon became routine for the one in 2 000 children born with a genital malformation.
But now many experts would like to see a change in that routine. They contend that surgery should be put off until the child is old enough to have a say in the matter.
"The surgery isn't actually done for the baby," says Cheryl Chase, founder and executive director of the Intersex Society of North America. "They do it, because they think it's disturbing to the parents."
"When a child is born with unusual genitals, the doctors take over," Chase says. "They say, 'We can fix it.' Parents don't have any information."
"The problem is, doctors aren't necessarily the people in our society who have a special understanding of sexual issues or emotionally difficult issues," she says.
'Protecting kids from ridicule'
The medical establishment generally has defended the surgeries, saying that intersex children would be ridiculed for not conforming to societal expectations of genital appearance. But critics don’t agree.
"Some kids are born with big ears," says Alice Dreger, an assistant professor of science and technology studies at Michigan State University who has researched extensively on intersex issues. "Do we say, 'My God, this kid can't survive with big ears?’"
The birth of a hermaphrodite baby, Dreger says, is not a medical emergency, but a psycho/social emergency.
"But we almost never call in a psychologist," she says. "We call in a surgeon."
Surgery's serious side effects
Surgeries and hormonal treatments are not reversible, she notes, and that can cause problems if adults don't fit the sex chosen for them in infancy. Surgery also can have side effects such as incontinence or a loss of sexual sensation.
Dreger proposes that hermaphrodites be treated as an anatomical variation, like differences in skin or hair colour, rather than as an abnormality.
Families of hermaphrodite children should receive psychological support, she says, and early surgery should be done only when there's a real medical concern, like urinary infection.
Dr William Reiner performed nearly 100 genital reconstructive surgeries at Johns Hopkins Medical Institutions in Baltimore before deciding to look at the psychology of intersex. He went back to school to get certified as a psychiatrist and now counsels intersex patients and their families as a professor of child and adolescent psychology at Johns Hopkins.
He, too, has become an advocate for delaying genital surgery on hermaphrodite babies.
Society's beliefs and genital surgery
"I think people are hung up about genitalia and sexuality," Reiner says. "We get mixed up, and these things scare us in some way. It may stimulate a drive to correct, a drive to make things right. Paediatric surgeons see all kinds of anomalies, and they are trained to make those anomalies normal."
But Reiner doesn't blame surgeons, saying they merely reflect the beliefs of society.
"We can't really blame this all on medicine," he says. "Part of it is a social problem. We have treated science as if it possesses the truth. It doesn't. Science is just a model."
"But we thought we were finding the truth," he says. "We thought we were God. We didn't realise that you can't make anybody anything. They are what they are."
"Philosophers have known for thousands of years that identity is built in, but in the last half of the 20th century, we thought identity could be created by society," Reiner says.
Nature, not nurture
In two studies, Reiner and other Johns Hopkins researchers found that prenatal exposure to normal male hormones determines male gender, even in chromosomal males born without a penis.
The researchers studied 27 genetically male children born with testicles but no penis, 25 of whom had been castrated at birth, "reassigned" and raised as females.
All 27 children showed strong male behaviours, and the majority reassigned themselves as males between the ages of 5 and 16.
"Rather than the environment forming these children's gender identity, their identity and gender role seem to have developed despite a total environment telling them they are female," Reiner says. "They seem to be quite capable of telling us who they are."
The two children in the study who weren't reassigned as females at birth were developmentally more like their male peers and psychologically better adjusted than the sex-reassigned children, the study shows.
"The solution is to leave them alone," Reiner says. "Most of them, by the time they're of kindergarten age, will figure out who they are."
And there still will be a role for surgeons.
"Eventually, they are almost all going to want surgical reconstruction," Reiner says. "So surgeons are still going to be reconstructing these kids."
"But instead of doing it at two days, two weeks or two months, it's going to be later," he says. "Will the surgeries be more difficult? Sure. But that's life."
"Better to have a difficult surgery on a 15-year-old than a beautiful surgical outcome on a one-year-old that turns out to be the wrong sex," he says.