What is Intersex and what does it mean for the Transgender conversation?

As an apologist, the pressing questions of culture always make it to my stage. I have spent the better part of the past year addressing the topic of transgenderism—a topic that has spiked within recent years and has left the Church rapidly trying figure out how to respond. Whenever I speak on transgenderism, almost always I will get asked in Q & A about the topic of Intersex. The idea is generally along the lines of, “Don’t Intersex people demonstrate that gender and/or sex is fluid because Intersex people represent a third gender or sex?” It is an important question to ask and spend more time on as it is the “I” in “LGBTQIA+.” What is Intersex? Is it a third gender? A third sex? Is it someone who is in between a male and female or both male and female?

What Exactly is Intersex?

For many people aged 30 and over, the term “intersex” is probably less commonly known than the term hermaphroditism. It is helpful to know that hermaphroditism as a term is outdated and no longer used.¹ The better term, intersex, or differences in sexual development (DSD)², refer to a series of conditions where there is something atypical or “different” with someone’s genetics, chromosomes, hormones, certain receptors etc. that cause problems with the formation and function of internal and external reproductive genitalia and fertility. That could mean they are missing certain reproductive organs, have external genitalia that are not fully formed, mismatched genitalia regarding their chromosomes, and issues with certain gene expressions. A human can be XXY, be considered intersex, and be male (more on that in a bit). While that may be confusing to many people who understand male and female based solely from chromosomes (XX is female, XY is male), it can be helpful to understand that while chromosomes are valid and significant, they are not the only way to determine the sex of an individual. There are multiple factors, including external physical appearance, and what I find even more helpful, considering one’s gametes, or what (egg or sperm) their body is aiming to produce. But it is important to note that no DSD ever creates a new gender or sex. The body develops towards the creation of male or female only, even if it is not successful.

How Can Gametes be Helpful?

While it is true in most cases that female mammals, such as a human, will be XX, and a male will be XY, it is not something that can be universally stated. For example, a platypus (also a mammal) has a 5X5Y karyotype (chromosomes) for males and 5X5X for females. As you can see, the mammal standard of two XX’s or one X and one Y is not helpful here. Outside of mammals, a female bird has a karyotype makeup of ZW, and a male bird is ZZ since they use altogether different chromosomes than humans. Likewise, the incubation temperature of turtle eggs determines whether the egg will be male or female. Cooler incubation temperatures will produce male eggs. Warmer temperatures will produce female eggs. As you can see, there are numerous ways in which male and female are identified in species across the board; the XX and XY chromosomal standard is not useful when examining species in the animal kingdom. To rectify this and to provide a consistent standard of determining biological sex across species, it can be helpful to consider the type of gametes an individual organism is set up to produce regardless of their chromosomes. If their bodies are following the pathway to produce large gametes (eggs), they are female. If it follows the pathway towards small gametes (sperm) they are male.³ 

What Does this Have to Do with Intersex?

The factors that go into understanding whether someone is male or female is extremely important to understanding what intersex really means and the sex of an intersex person. For example, someone with the intersex condition 47, XXY commonly referred to as Klinefelter syndrome⁴, is considered male, although they have two XX’s in their karyotype. There are a few reasons why. First, the presence of the Y is essential. It is what moves the body towards the male pathway for reproduction. Without it, the body will develop female. Second, while the extra X chromosome massively inhibits sperm production (causing most to have little to no sperm)⁵, because the body is forming itself along the developmental pathway to produce the male gamete, sperm, a person with this condition is male. Someone might see that this person has two XX’s and a Y, and wrongly assume that they are a cross between a male and female, but that is not the case. They do not possess both egg and sperm, they are not XX AND XY, nor do they possess both reproductive systems. 

Similarly, the intersex condition 5-alpha reductase (46, XY), is caused by a gene mutation on Chromosome 2. This mutation causes testosterone to not be converted to Dihydrotestosterone (DHT). This important hormone is what causes male external genitalia to develop while in utero. Without this, a child is born looking externally female, ambiguous, or only slightly male. This often leads to a baby being misidentified as female at birth. Often this condition is not discovered until puberty because at that time, due to the normal large boost of testosterone, their external genitalia “masculinizes,” and their male sex identity becomes clearer. A karyotype test will further identify that the individual is of the typical genetic karyotype for a male, 46, XY, and other testing would indicate a male reproductive system and hormone levels. These results would clear up any confusion that they were ever female to begin with.

Additionally, another 46, XY Intersex condition is called “complete androgen insensitivity syndrome” (CAIS). This intersex condition is a bit more complicated to understand because although this individual possesses the typical 46, XY karyotype for a human male, someone with this condition develops into a female. In utero, testosterone is essential to forming the internal male ducts and external male genitalia, but someone with this condition is unable to respond accurately to testosterone due to a problem with their Androgen receptor’s (AR). Androgens are the male sex hormones. Receptors help the body to effectively use those hormones. Because of the mutation in the AR gene, these receptors cannot bind to the testosterone so that the body can use it properly; the body is unable to utilize the testosterone to internally or externally masculinize the developing baby.⁶ As a result, the testosterone created by the body is converted to estrogen and it feminizes the person. This person grows up with a complete feminine appearance including low body hair, typical female breast development and external genitalia, and are therefore considered female. 

Our Bodies are Designed to be One Sex

One important thing to learn from CAIS is that this particular condition leaves the person infertile because testosterone was never able to develop the male internal ducts and the presence of the Y chromosome caused the female reproduction system to not form. What is often not understood in the transgender/intersex conversation is that the body is uniquely hard wired to never be fully both male and female, but to only be one or the other. This can be referred to as mutually antagonistic. This is seen even on a cellular level developmentally when the person only follows a male or female track. In utero, before any reproductive changes happen, a baby possesses what are called Wolffian ducts (male primitive reproductive tissue) and Mullerian ducts (female primitive reproductive tissue). It is important to note that neither of these are full reproductive systems, rather the foundation from which those systems will be built should the proper chromosomes and genes be in place.⁷ If the child is XY, on the Y chromosome will be located the SRY gene. Around the 7- or 8-week mark, this gene leads to testes formation which then produce anti-Mullerian hormone (AMH) and testosterone. The testosterone will grow the Wolffian ducts into male internal reproductive ducts and grow the external genitalia, while the AMH shuts down the Mullerian ducts thus stopping any female internal reproductive organs from developing. The Mullerian ducts will simply regress and dissolve back into the body. Likewise, if the baby is XX, there will be no SRY gene (since there is no Y chromosome) to produce testes and subsequently testosterone and AMH. Since the body will naturally follow a female pathway unless inhibited upon by the SRY gene, the body forms female including ovaries and the development of the Mullerian ducts into the female reproductive system. Without testosterone present causing the Wolffian ducts to grow, they will disintegrate into the body and disappear. As you can see, the human body is designed to form either male or female and has systems in place to make that happen. 

What Now?

What can be helpful in the conversation on intersex is to acquire a more precise understanding of the condition. Common misunderstandings of what an intersex person is (such as both male and female) play heavily into our understanding, not only of transgenderism but also of our potential to actually become the other sex. Intersex people do not appreciate being misunderstood or looked at as “weird” because they developed differently. The intersex community also does not advocate for non-lifesaving operations on intersex children of young ages; rather, they believe that it is best to wait until the children reach an age in which they will naturally have a clearer idea of their gender.⁸ 

Additionally, intersex people are often used to justify that being male and female is fluid and therefore, someone born without an Intersex condition, can move away from their male/female biological reality and create a new male/female identity. Let us not let misinformation about intersex persons cloud the truth. Human reproduction necessitates that certain processes happen regardless of how we may want to play semantics with the definitions. Any attempts to muddle the male/female binary reality by taking hormones and/or doing genitalia surgery causes problems with human reproductive functionality. If we want to argue that we can all make medical changes to our bodies and turn them into whatever we want, then we cannot ignore the larger and more catastrophic impact that would have on the ability of humanity to survive into the future. All the Intersex conditions pose physiological and many pose fertility challenges. An intersex DSD never creates a new sex or gender, rather it demonstrates what happens in an imperfect world when there are problems in utero along the biological pathways of development to being male or female. Someone who is intersex did not choose to be.

I recently met a teenager with CAIS. Despite her situation, she was happy and thankful to be alive. While she grieved over never being able to have biological children, she had come to terms with the fact that God must want her to adopt, and that is exactly what she plans to do. For her, the transgender movement leads to frustration because while so many people are transitioning and removing healthy reproductive organs, all she wants is to have her own reproductive organs so she can take part in bringing life into the world. Listening to her speak about what is lost for her only affirmed to me the tragedy of the destructive surgeries so many have experienced in their attempts to be someone other than themselves.

Intersex people are beloved by God and are also created in his image. They are your family members, co-workers, neighbors, and friends. Human development is an extremely complex process. In an environment where so much needs to go right for there to be no disruptions in fetal development, it is miraculous that we do not see intersex conditions more often. We can embrace those whose development proceeded despite great challenges such as in the intersex case of Turner syndrome, which affects 1-2% of conceptions. Of that 1-2%, about 99% of those conceptions are miscarried or stillborn.⁹ That means that the 1% who are born with this condition, while intersex, are actually the miracle babies! They are the ones who survived only having an X chromosome with no X or Y to accompany it to complete the typical development–producing a little life that is always beautiful and always valuable indeed!