A Scientific and Theological Response to the Intersex Question
One of my finer teaching moments the last time I taught gender theory was successfully luring my students into the following thought-trap. During one of our class discussions, I noticed some students parroting the line that biological sex is “assigned” at birth by doctors and parents rather than identified or recognized. “Wait a second,” I said. “Is sexual orientation innate, something we are born with?” My students nodded readily. This is well-established dogma. “And you’re also saying that biological sex is a social construct, a category arbitrarily ‘assigned’ at birth?” More vigorous nods. “How is that possible? Aren’t those claims contradictory? How is it possible to have an innate attraction to something that is merely a social construct?” Aha. In that millisecond, I saw a brief glimmer of light cut through the postmodern haze. Even if they quickly turned away, they had at least recognized the contradiction.
The bizarre idea that biological sex is “assigned” at birth for everyone is one of several myths about sex that have gained widespread acceptance in our time. These myths tend to cluster together, like one trapdoor that opens into another. Once you accept one myth as true, you quickly free fall down the rabbit hole. The first trapdoor is this idea: sex is not binary but a spectrum. This leads to the notion that the categories “male” and “female” are social constructs, rather than terms that correspond to an objective truth about human nature. If sex is a construct, then the labels “girl” and “boy” are indeed “assigned” by doctors, who thus create the illusion of a binary. Lastly, if birth sex is not identified from the body, but projected onto the body, then sex can be changed.
The gateway into this spiral of myths is the contention that sex is not binary—in other words, the contention that there are more than two sexes or that sex is a spectrum. The question is: do we have good evidence to support this contention? Come! Let’s take a magical mystery tour through the science of sex.
The Science of Sex
Human bodies are teleologically organized according to our distinct role in reproducing the species. The structure of our bodies is arranged to produce either large sex cells or small sex cells. These sex cells are called gametes. Large gametes are ova, and small gametes are sperm. A physiology arranged to produce ova is female, and a physiology arranged to produce sperm is male. This twofold distinction between large and small gametes is stable and universal, not only throughout the human species, but also among all plant and animal species that reproduce sexually.
There is no such thing as a third gamete or a spectrum of possible gametes. This invariable feature of our humanity ties us intimately to the rest of creation. When the gametes combine, they can create a new member of the species. The sex binary, then, is the necessary foundation for the continued transmission of human existence (if it’s just a construct, we’re in trouble).
Rather than arbitrarily assigned at birth, a baby’s sex is determined at conception, through the SRY gene (or its absence). This gene is the master switch of sexual differentiation; if triggered, the SRY gene initiates a process of sexual development toward the production of male gametes. Without successful SRY activation, the gonads of a developing baby become ovaries, which are structured to produce female gametes.
If the science is clear, and the sex binary in humans has existed for millions of years—why are we suddenly facing the novel notion of sex as a spectrum? Elsewhere I have sketched out a possible genealogy for this idea; here, I would like to respond to two central arguments behind the spectrum hypothesis.
This is by far the most common rejoinder I hear: “Sex is not a binary. Intersex people exist.” Foot soldiers of the gender brigade always make sure to carry the intersex card in a ready holster and are quick on the draw. This reflexive reference to intersex is a great rhetorical move because most people don’t know enough about the topic to make a cogent response. The term is used in such a way to suggest that “intersex” refers to something completely outside the male/female binary, like some third sex or non-sex category of persons who are neither male nor female, or somehow both male and female. In this way, the intersex trump card is used to erase the fundamental and stable reality of biological sex, in order to justify the idea that sex is a construct and open the door to limitless self-identification.
The term “intersex” is an umbrella term encompassing a range of conditions that disrupt the development of certain sexual characteristics. Despite its prevalence in the gender theory world, the term is imprecise and often misused. Medical literature tends to use the term “disorders of sexual development” (DSDs). I have also seen “differences of sexual development” and “variations of sexual development” (VSDs). I prefer the term “congenital conditions of sexual development” (CCSDs), which is medically precise and avoids the language of “disorder” that some find stigmatizing. Moreover, including the word “congenital” helpfully limits the range of conditions; while late-onset disruptions of sexual development can occur, these do not result in sexual ambiguity at birth. If “intersex” is used to invoke a category in between the sexes, it is a misnomer. However, the label can be accurately used when referring to a biologically based variation within maleness or femaleness.
I first encountered the concept of intersexuality in graduate school, when I was studying gender theory. I came across the book Sexing the Body by biologist Anne Fausto-Sterling and found it utterly fascinating. I had never done a deep dive into the complexities of sexual development before, and her radical conclusions blew my hair back. I used this book as a primary source in the culminating project for my master’s coursework, in which I argued that science itself is a gendered discipline with an inherent masculine bias (an entertaining but ultimately flawed line of argumentation).
Fausto-Sterling is the fairy godmother of the intersex gambit, that tokenizing reference to intersex people used to dismantle the idea of a sex binary. Her work is also the origin of common misconceptions about CCSDs, such as the idea that these conditions are as common as having red hair. In a coauthored article “How Sexually Dimorphic Are We?”, Fausto-Sterling et al. argue that sex should be understood as a continuum, rather than a binary, and a key part of their argument is the notion that intersex conditions are fairly common, occurring in as many as 1.7 per 100 live births (1.7%). They arrive at this number through an overly expansive definition of intersex, one that includes any “individual who deviates from the Platonic ideal of physical dimorphism at the chromosomal, genital, gonadal, or hormonal levels.” This capacious definition would include conditions such as polycystic ovarian syndrome (PCOS), a hormonal disorder that occurs when a woman produces excess androgen, or Klinefelter syndrome, when a man has an extra X chromosome (it might even include me—my body hair situation is decidedly not in line with the Platonic ideal!). While these conditions may lead to fertility problems, they do not cause sexual ambiguity. A woman with PCOS is clearly female, and a man with Klinefelter is clearly male, often unaware of his chromosomal variation until he attempts to have children.
In fact, the five most common conditions that Fausto-Sterling categorizes as “intersex” do not actually involve instances of sexual ambiguity. When we restrict the category to include only such cases, the number plummets to 0.018%—a figure one hundred times lower than Fausto- Sterling’s estimate. Rather than the inflated rate of 1.7 out of 100 births, CCSDs occur in fewer than 2 out of 10,000 births. This is a crucial point to understand: the vast majority of individuals often categorized as intersex are unambiguously male or female, even if the presentation of maleness or femaleness is atypical in some way.
Take the condition of vaginal agenesis, which Fausto-Sterling categorizes as intersex. Baby girls born with this condition have a vagina that is not fully developed, along with fully functioning ovaries and female sex characteristics. In Fausto-Sterling’s logic, a girl with vaginal agenesis is not “really” female. Ironically, her attempt to critique the Platonic ideals of maleness and femaleness actually reinforces those ideals, by exempting those with variations in sexual development from the sex binary altogether.
Given the fact that sexual development is a process and at each stage of the process, things can go awry, I am actually surprised how rare cases of genuine sexual ambiguity are. I’m not surprised such cases exist; rather, I’m surprised there are so few. Statistically speaking, sex is readily recognizable at birth for 99.98% of human beings. That is remarkably consistent. In the remaining outlying cases, the reality of sex is still present but must be more carefully discerned—not for curiosity’s sake, but in order to support the person’s physical health. This is not because those individuals are neither male nor female, but rather because their developmental pathways of becoming male or female took some unexpected turns.
Discerning sex in these individuals entails looking at multiple factors taken together: karyotype (chromosomes); phenotype (genitalia); gonads (ovaries or testes); internal structures that support gamete production; and hormones. Sexual ambiguity occurs when the phenotype is not readily classifiable as male or female or when the karyotype is not consistent with the phenotype, as in cases of complete androgen insensitivity syndrome (CAIS). Overly broad use of the term “intersex” tends to privilege karyotype and phenotype, while overlooking gamete production and—most importantly—the structure of the body as a whole. In the face of ambiguity in these first two factors, genderists tend to conclude prematurely that the verdict is in: the sex binary is false. Popular memes, such as the Genderbread Person, portray sex on a spectrum and define sex as a mix-and-match assemblage of “genitalia, body shape, voice pitch, body hair, hormones, chromosomes, etc.” Gamete production is not mentioned at all, even though this is the foundation of biological sex.
This reflects a common error: reducing biological sex to secondary sex characteristics—seeing sex as merely about genital appearance or breast development. The gender paradigm fundamentally misunderstands what sex is, confusing cause with effect. Secondary sex characteristics develop as a consequence of sex; they are the effect, rather than the cause.
This misunderstanding is often perpetuated to reach a desired conclusion: the notion that a person can change his or her sex. If sex is defined by secondary characteristics like genital appearance and voice depth, then changing sex is possible, through surgery and synthetic hormones. If, however, sex is fundamentally about how the entire body is organized in relation to gamete production—a potentiality that cannot be endowed by a scalpel—then the undeniable truth is this: it is not possible to change one’s sex, because sex is constitutive of the whole person.
When faced with ambiguity at the level of phenotype and karyotype, the best response is not to shrug and embrace the spectrum, but to continue the discernment of sex by looking at the anatomical structures that support either large gamete production or small gamete production. Although the term “hermaphrodite” used to be applied to cases of sexual ambiguity, this is a dehumanizing misnomer. Hermaphrodites are species that do not have separate sexes, such as snails and slugs; instead, each member of the species has the ability to produce both large and small gametes and can thus take on either the “male” or “female” role in reproduction. For this kind of species, hermaphroditic reproduction is the norm. Human biology, on the other hand, does not support this mode of reproduction. In the rarest CCSD, an individual can develop both ovarian and testicular tissue, but even in this case, he or she will produce one gamete or the other, not both. There have only been about five hundred documented cases of an ovotesticular CCSD in all of medical history, and there is no direct evidence in the literature of a hermaphroditic human being, someone able to produce both small and large gametes.
When all the dimensions of sex are taken into account, sex can be discerned in each human being. To conclude otherwise is to exclude some individuals from a reality in which we all participate. This kind of thinking has unintended and harmful consequences, ones that lead to bodily violation.
Despite its flaws, one of the most valuable aspects of Fausto-Sterling’s work is her critique of infant genital mutilation (IGM), medically unnecessary surgeries on infants born with CCSDs. This used to be standard medical practice. If a baby was born with atypical or ambiguous genitalia, the reaction was to whip out the scalpel and attempt to sculpt more normal-looking genitals. An infant girl born with an enlarged clitoris (clitoromegaly) might be subjected to unnecessary genital surgery to make the clitoris appear more normal. Surgeries like this, which are purely cosmetic, can lead to reduced sexual function and sensation.
Even more disturbing: a healthy infant of one sex might be categorized and raised as the opposite sex, simply because of the external appearance of the genitals. This is the situation in which the phrase “assigned sex” is accurate: a baby boy with a micropenis might have been surgically altered and raised as a girl, simply because his male genitalia didn’t match the norm. It is easier to surgically mimic the appearance of a vagina, so infants with ambiguous genitalia were more regularly designated “female,” regardless of overall bodily structure. I remember this chilling line from Fausto-Sterling’s book, which she attributed to a surgeon: “You can make a hole, but you can’t build a pole.”
The animating problem behind the practice of IGM is an idealization of how male and female genitalia should look. The emphasis is on cosmetic appearance, rather than respect for the integrity of the body and how the body is organized as a whole.
Intersex activism first arose in the 1990s—not as an attempt to dismantle the sex binary, but rather to end harmful medical practices and raise awareness of CCSDs. The Intersex Society of North America (ISNA) successfully advocated for groundbreaking changes in the healthcare system. Clinical guidelines published in 2006 established new protocols for responding to infants with CCSDs, including a more cautious approach to surgical intervention, with attention to bodily function and medical necessity rather than appearance. After these successes, ISNA disbanded in 2008, which is around the time I first studied intersex conditions in graduate school. At the time, it seemed like we were entering a new era of respecting the dignity and bodily integrity of people with CCSDs, but the mainstreaming of postmodern gender theory is reversing that progress.
Proponents of the sex spectrum claim to be allies of people with CCSDs, and I am sure most are acting in good faith. But the knee-jerk invocation “Intersex people exist!” is used to cast doubt on the reality of biological sex rather than to cultivate an awareness of the unique circumstances and needs of people with CCSDs. Ironically, postmodern genderists fall into the same error as those surgeons who performed unneeded surgeries: they place undue emphasis on idealized stereotypes of how men and women should look. If we refer to the Gender Unicorn—an Internet meme that distills postmodern gender theory into a cartoonish diagram—there are three options listed for “sex assigned at birth”: male, female, and other/intersex. This meme classifies “intersex” as something other than male or female, a mischaracterization commonly found in activist rhetoric. Unfortunately, this way of framing CCSDs dehumanizes intersex individuals by insisting that any deviations from idealized norms are not “really” male or female, but “other.” In this understanding, a girl born with atypical genitalia is expelled from the category “female” altogether and placed in some amorphous third category or marooned along a spectrum between maleness and femaleness.
Increasingly, the term “intersex” is invoked as a “gotcha!” card in debates about transgender identities. The addition of an “I” to the ever-expansive LGBTQIA+ acronym conflates, in a reductive and unhelpful way, the very different situations of individuals with CCSDs and trans-identifying people. One notable point of tension is the question of bodily integrity.
The intersex activist effort has focused on ending mutilating surgeries, valuing health and wholeness over idealized appearance and preserving the integrity of the body in whatever form it comes. These efforts are in tension with transgender activism, which advocates invasive surgeries on healthy bodies, values cosmetic appearance over health and bodily function, and does not respect the integrity of the body as a good that should be preserved. The procedures that intersex activists describe as “mutilations” are the same procedures that trans activists insist are good and necessary, even for minors. IGMs are rightly decried not simply because they are nonconsensual—although this is a crucial factor—but also because they do unnecessary harm to the body. For the trans activist, the integrity of the body matters only when I want it to matter. The underlying fantasy of postmodernity is that we have control over our nature, that we are the masters, the gods, the makers. Rather than affirming that fantasy, people with CCSDs expose it as false, because they are reckoning with bodily realities outside of their control.
There have been some attempts to categorize trans-identifying people as intersex, usually by appealing to the idea of a congenital “brain sex” that does not align with bodily sex. Several neuroimaging studies have explored the hypothesis that the brains of trans-identified people bear greater similarity to the brains of their professed gender than their natal sex. There are problems with this theory on three distinct levels. First of all, there is no solid evidence for an association between brain structure and trans-identification. The neuroimaging studies that exist are small and very limited and generate inconclusive and contradictory results (see here, here, and here)
Secondly, even if we had solid evidence for these structural and functional brain differences, due to neuroplasticity, the causal relationship would remain unclear. In other words, it would be impossible to tell if such differences were congenital and led to trans-identification or if trans-identification and transition had rewired the brain. Thirdly, even if we had solid evidence for this association and evidence that it is congenital like an intersex condition, we still arrive at another problem: why should sex be defined according to neuroanatomy rather than the presence of a healthy reproductive system, when sex is fundamentally a reproductive category? Redefining sex according to brain structure and function would mean that any woman or man whose neuroimages deviate from the norm is not “really” a woman or a man at all. I am not denying that some cases of sexual incongruence might have a neurological basis. That is certainly possible. What I am disputing is the idea of “brain sex,” which is not supported by evidence and contradicts a basic biological understanding of what sex is.
Let me gather the important threads here. Sex is not a spectrum but a stable binary—not only in the human species but in all sexually reproductive plant and animal species. There is no third sex. There is no spectrum of possible sexes.
In the process of sexual development, there can be variations that lead to atypical manifestations of maleness and femaleness. In 99.98% of these cases, sex is readily recognizable as unambiguously male or female. Categorizing these individuals as “intersex” or “other” leads to the idea that some women are “more” or “less” female based on how closely their bodies approximate the norm. Am I “less” female because I have more facial and body hair than the ideal? Am I less of a woman because, as I was told in high school, my legs look like a man’s legs? This way of thinking draws a narrow, superficial box around maleness and femaleness and demeans anyone who falls outside its bounds.
The 0.02% of cases where sex is not readily identifiable do not represent a third sex or points on a spectrum. Even here, sex is present and must be discerned with an attention to the whole person and supporting his or her physical health. These extremely rare situations are by definition unique and particular, and the focus must be on the individual’s specific needs. Some CCSDs, like other congenital conditions, require medical attention and management, in order to maintain bodily health and integrity.
Co-opting the existence of intersex people to promote a postmodern understanding of sex and gender is unjust. The most humanizing and precise way to view CCSDs is to understand these conditions not as exceptions from the sex binary, but as variations within the binary. We need to make room within the boxes of male and female for a diverse range of body types and personalities. We do not need to abolish the boxes altogether.
Body as Sacrament
I’ve been spending a fair bit of time here on the biological plane. It’s important to understand what sex is, and how sexual development unfolds, in order to be able to counter the postmodern myths. That can’t be the extent of our discussion, however, if we’re thinking from a Christian perspective. Our consideration of sex and gender must be attuned to the holistic and sacred reality of the person—the person as an integrated unity of body and soul. We must follow a path of contemplation that sees the various dimensions of personhood in order to receive the miracle of each person. This is a path that moves toward integration, from disorder to wholeness. The postmodern approach to sex and gender runs in the opposite direction, into fragmentation, a piecemeal self, where body and psyche and desire are split off from one another and rearrangeable—where the body is not the foundation of personal identity, but rather its lifeless tool.
In contrast, the personalist approach allows us to see each human being as a person, rather than a collection of ever-proliferating labels, and, more importantly, to attune our awareness to the sacramentality of every human body. Bodies are not “just” bodies. Bodies are persons made manifest. The sacramental principle is always at work: the visible reveals the invisible. The body reveals to us the eternal and divine reality of the person—a reality that can only break into the tangible, sensible world through embodiment.
That is how God enters into our world and reveals himself, through the incarnational reality of Christ, who became a body that we might know and love the invisible God. The Incarnation is both a historical moment, a plot on the timeline of the world story, and an eternal moment. The divine Person who quickened in the womb of Mary is also the Person who, in the Eucharist, clothes himself in the molecules of wine and bread, that he might be placed on our tongues and engulfed by our hearts. This mystery—the sacramental mystery of the Incarnation—should frame our vision of all that is.
Too easily, we lose sight of this mystery; we allow our vision to contract, to become superficial and self-serving. We fall into the perennial error of seeing some human bodies as not-quite-human and thus disposable, cast out of the circle of what’s seen and what’s valued.
This time-worn tendency is on glaring display in Flannery O’Connor’s story “A Temple of the Holy Ghost.” Told from the perspective of an imaginative child who fantasizes about heroic martyrdom while skimping on her prayers, this story casts a bright beam on the dignity and sacramentality of the intersex person.
There’s a fair in town, one with a Ferris wheel, merry-go-round, and “closed tent” exhibits for adults only. The child protagonist hears two older girls talking in hushed tones about what they saw in one of the tents: a “freak” that was “a man and woman both.” This person had “a particular name,” but the girls don’t remember it, instead using demeaning terms like “you-know-what” and the excising pronoun “it.”
The child, being a child, is not allowed into the closed exhibit, but her robust imagination embellishes the scant details provided by the older girls. She imagines the exhibit like a tent revival, the intersex person as preacher: “God made me thisaway . . . God done this to me and I praise him.” The people murmur, “Amen. Amen.” The preaching goes on: “Raise yourself up. A temple of the Holy Ghost. You! You are God’s temple, don’t you know? God’s Spirit has a dwelling in you, don’t you know? . . . A temple of God is a holy thing. Amen. Amen. I am a temple of the Holy Ghost.”
This fantasy of a communal worship service led by the intersex person stands in stark opposition to how the town’s religious authorities actually respond. By the end of the story, we learn that the fair has been closed prematurely after the town preachers do an inspection and tell the police to “shut it on down.” Rather than whispering “amen” and praising God for his handiwork, the townsfolk say “begone.”
In one of her personal letters, O’Connor explains how that intersex character is the only person who approaches holiness in the story. She writes, “as near as I get to saying what purity is in this story is saying that it is an acceptance of what God wills for us, an acceptance of our individual circumstances.” Only the intersex person displays that spiritual wisdom, the purity of self-acceptance, a purity made even more remarkable in the face of ostracism.
The closing section of the story centers on another kind of exhibition: Eucharistic Adoration, the Catholic practice of sitting in reverence before a consecrated Host, the small circle of bread that has been changed by the Holy Spirit into the Body of Christ. This form of Christ’s Body is unexpected, dazzling our assumptions about what should be.
When the child sees the raised monstrance with the Body of Christ “shining ivory-colored in the center of it,” she thinks again about the person from the closed tent, and she hears that person say, “This is the way He wanted me to be.”
Through this religious imagery, O’Connor deftly portrays two truths simultaneously. First, the undeniable fact that people with unexpected bodies are often shunned, scapegoated, and dehumanized. This is still happening. Despite its so-called progressivism, the current portrayal of intersex people as neither men nor women is simply the latest version of this othering—the updated, politically permissible way of saying “freak” and “it”.
Secondly, O’Connor is drawing a profound parallel between the intersex person and Christ himself. Like Christ, the person’s identity baffles and confuses the crowd. Like Christ, the person is shunned, mocked, and rejected. Like Christ in Adoration, the person’s body is on display. Just as Christ’s divine personhood is made visible by his eucharistic Body, the intersex body is likewise a revelation, a sacramental image of the living God and a temple of his indwelling Spirit. The extended parallel highlights the hypocrisy, the inherent contradiction, of adoring the Body of Christ, his divinity and humanity—while denigrating the intersex body, which carries divine dignity.
This story calls us to take a posture of adoration, to see all of reality, and every human being, through the illuminating mystery of the Incarnation. Each body is an icon of Christ; each body is a sacrament, revealing to us the sacred and unrepeatable mystery of the person. Let our knees tremble in wonder at this. Amen, amen.
EDITORIAL NOTE: This essay is an excerpt from The Genesis of Gender: A Christian Theory (122–139), courtesy of Ignatius Press, All Rights Reserved.