A recent article published on CNN discusses the lives of two teens in Palestine raised as girls but transformed by puberty into boys. These teens most likely have a condition called 5-alpha-reductase deficiency (5-ARD), one of several intersex conditions (disorders of sex development) that alters the masculinization of XY fetuses before they are born. Unfortunately, the article uses outdated words and phrases such as “pseudohermaphrodism” and “sex-change operations” that should no longer be used because they are offensive. However it does raise awareness and give face to a group of people who are usually hidden away.
All fetuses have the same internal and external genitalia until about 8 weeks of gestation. Then various hormones act to differentiate the sexes by developing some parts and regressing others. But there are many steps involved and DNA mutations can modify this outcome. I suspect that Caster Semenya, the recently contested 2009 gold medal winner of the 800 meter race at the World Athletics Championships, has androgen insensitivity syndrome (AIS). If this is so, her XY chromosomes and testes were unable to masculinize her body as it formed; a defective hormone receptor prevents her body from responding appropriately to the male hormones it produces. However, her receptors may be only partially impaired and thus give her, in some people’s view, an unfair advantage over her competitors. The allegations, the subsequent gender verification studies and the fallout therefrom continue to embroil her in international controversy. But what makes a woman a woman? If she isn’t a woman than what is she? She certainly isn’t a man.
The Palestinian teens discussed in the article have a different mutation. Like Caster, they probably have XY chromosomes, testes and appeared just like any other girl when they were born. Yet while their hormone receptors work, they lack the enzyme needed to convert testosterone into its more powerful form, dihydrotestosterone (DHT). Their bodies appeared female before puberty because the amount of testosterone produced was insufficient to make up for the absent DHT. After puberty began their testosterone levels went through the roof just like every other adolescent boy. This brought along the changes the go with it including facial hair, deeping voice and musculoskeletal changes. Their clitorises probably enlarged significantly just as penises do. But do these teens really feel that they are now men or do they still feel that they girls inside of bodies that have betrayed them?
“Only my appearance, my haircut and clothing, makes me look like a boy,” Ahmed says, gesturing with his hands across his face. “Inside, I am like a female. I am a girl.”
Why do we care if Caster and these teens are men or women, one or the other? Is it right for society to force them to change to uphold the myth of binary gender? When you really think about it, no one fits the stereotype completely; no one is or every was the ideal man or the ideal woman. They are only fantasies. Instead we are all composites, not one of us pure in form. We exist somewhere in the middle leaning this way and that in varying degrees depending on which attribute we consider. Gender is so much more than the 2 little check boxes “male” and “female.” Maybe someday we will learn to allow each other the space to simply be who we are. A world without labels and boxes, without simplification and alteration. We will finally see the world as it already is.
James Pate, MD 