Sex assignment refers to the assigning of sex at the birth of a baby. In over 99.9% of births, a relative, midwife, or physician inspects the genitalia when the baby is delivered, sees ordinary male or female genitalia, and declares, "it's a girl" or "it's a boy" without hesitation or uncertainty. The assignment is perceived as a recognition of an essential aspect of this new human being, apparent to everyone. In nearly all cases, usually without conscious deliberation, the parents rear the child as a member of the assigned sex/gender. Look up Sex in Wiktionary, the free dictionary. ... Childbirth (also called labo(u)r, birth, partus or parturition) is the culmination of a human pregnancy with the emergence of a newborn infant from its mothers uterus. ... The term baby can refer to: an infant a very early computer—the Small-Scale Experimental Machine, nicknamed Baby a musician – Brian Williams – who performs under the name Baby. ... Midwifery is a blanket term used to describe a number of different types of health practitioners, other than doctors, who provide prenatal care to expecting mothers, attend the birth of the infant and provide postnatal care to the mother and infant. ... Physician examining a child A physician is a person who practices medicine. ... A sex organ, or primary sexual characteristic, narrowly defined, is any of those parts of the body (which are not always bodily organs according to the strict definition) which are involved in sexual reproduction and constitute the reproductive system in an complex organism; namely: Male: penis (notably the glans penis... The shield and spear of the Roman God Mars are often used to represent the male sex In heterogamous species, male is the sex of an organism, or of a part of an organism, which typically produces smaller, mobile gametes (spermatozoa) that are able to fertilise female gametes (ova). ... The mirror of the Roman Goddess Venus is often used to represent the female sex. ... Gender of rearing is the gender in which parents rear a child. ... The word gender describes the state of being male, female, or neither. ...

The act of assignment is a social act, and is in nearly all cases, and all societies, an act that seems a simple recognition of a simple biological reality. However, the usual act of assignment carries with it some conscious and unconscious assumptions, namely that the external genitalia reflect other aspects of biological sex, such as internal anatomy, gonads, hormones, and chromosomes. The act of assignment usually carries the implicit expectation that future gender identity will develop in the gender of anatomy, assignment, and rearing. Look up Sex in Wiktionary, the free dictionary. ... The gonad is the organ that makes gametes. ... A hormone (from Greek horman - to set in motion) is a chemical messenger from one cell (or group of cells) to another. ... Figure 1: Chromosome. ... This article or section does not cite its references or sources. ...

In a minority of cases one or more of these assumptions prove false. There have been rare instances where parents (for a variety of reasons) have reared a biologically normal child in the opposite gender. More commonly, in the case of some transgender or intersex individuals, gender identity does not simply follow the biological sex or sex of rearing. In some conditions usually termed intersex, the external anatomy does not reflect accurately the internal anatomy. Transgender is an overarching term applied to a variety of individuals, behaviors, and groups involving tendencies that diverge from the gender role (woman or man) commonly, but not always, assigned at birth. ... An intersexual is a person (or individual of any unisexual species) who is born with genitalia and/or secondary sexual characteristics of indeterminate sex, or which combine features of both sexes. ... An intersexual is a person (or individual of any unisexual species) who is born with genitalia and/or secondary sexual characteristics of indeterminate sex, or which combine features of both sexes. ...

Assignment in intersex conditions

Intersex is a broadly defined term that usually denotes the presence of discordance of the biological aspects of sex: at least some aspect of the genitalia, internal organs, gonadal tissue, or chromosomes is more typical of the other sex, or incompletely differentiated. When the external genitalia appear to be "in between", they are described as ambiguous. An intersexual is a person (or individual of any unisexual species) who is born with genitalia and/or secondary sexual characteristics of indeterminate sex, or which combine features of both sexes. ... The gonad is the organ that makes gametes. ... Figure 1: Chromosome. ... Sexual differentiation is the process of development of the differences between males and females from an undifferentiated zygote (fertilized egg). ... An intersexual is a person (or individual of any unisexual species) who is born with genitalia and/or secondary sexual characteristics of indeterminate sex, or which combine features of both sexes. ...

In approximately 1 in 5,000 infants there is enough variation in the appearance of the external genitalia to give rise to hesitation about appropriate assignment by the physician involved. Typical examples would be an unusually prominent clitoris in an otherwise apparently normal girl, or complete cryptorchidism or mild hypospadias in an otherwise apparently normal boy. In most of these cases, a sex is tentatively assigned and the parents told that tests will be performed to quickly confirm the apparent sex. Typical tests in this situation might include a pelvic ultrasound to detect a uterus, a testosterone or 17-hydroxyprogesterone level, and/or a karyotype. In some of these cases a pediatric endocrinologist is consulted to confirm the tentative sex assignment. The expected assignment is usually confirmed within hours to a couple of days in these cases. A womans clitoris extends from the visible portion to a point below the pubic bone. ... Cryptorchidism is a medical term referring to absence from the scrotum of one or both testes. ... Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urethral meatus (opening). ... A baby in its mothers womb, viewed in a sonogram A baby, aged 29 weeks, in a 3D ultrasound Ultrasound is sound with a frequency greater than the upper limit of human hearing, this limit being approximately 20 kilohertz (20,000 hertz). ... The uterus or womb is the major female reproductive organ of most mammals, including humans. ... Testosterone is a steroid hormone from the androgen group. ... 17-hydroxyprogesterone ( also 17-OH progesterone, or 17OHP))is a C-21 steroid that is derived from progesterone by 17-hydroxylase, a P450c17 enzyme, and is a prohormone for both glucocorticoids and androstenedione, a precursor for sex steroids. ... Karyogram of human male A karyotype is the complete set of all chromosomes of a cell of any living organism. ... Pediatric endocrinology is a medical subspecialty dealing with variations of physical growth and sexual development in childhood, as well as diabetes and other disorders of the endocrine glands. ...

In a much smaller proportion of cases, the process of assignment is more complex, and involves both determining what the biological levels of sex may be as well as choosing the best sex assignment. Approximately 1 in 20,000 infants is born with enough ambiguity that assignment becomes a more drawn-out process of multiple tests and intensive education of the parents about sexual differentiation. In some of these cases, it is clear that the child will face major discordances or abnormalities of anatomy or function as he or she grows up, and deciding upon the sex of assignment is a matter of weighing the advantages and disadvantages of either assignment. Sexual differentiation is the process of development of the differences between males and females from an undifferentiated zygote (fertilized egg). ...

Criteria for assignment in these cases have evolved over the decades, as our understanding of the biological factors and our diagnostic tests have improved, as surgical techniques have changed and potential complications have become clearer, and in response to the outcomes and opinions of adults who have grown up with various intersex conditions. Intersex surgery is one of several terms referring to surgery performed to correct birth defects or early injuries of the genitalia, primarily for the purposes of making the appearance more normal and to reduce the likelihood of future problems. ...

The following is a brief review of the history of the criteria for sex assignment in intersex cases.

Before the 1950s, assignment was based almost entirely on the appearance of the external genitalia. Although physicians recognized that there were conditions in which the apparent secondary sexual characteristics could develop contrary to the person's sex, and conditions in which the gonadal sex did not match that of the external genitalia, their ability to understand and diagnose such conditions in infancy was too poor to attempt to predict future development in most cases.

In the 1950s, endocrinologists developed a basic understanding of the major intersex conditions: (congenital adrenal hyperplasia (CAH), androgen insensitivity syndrome, mixed gonadal dysgenesis and other chromosomal abnormalities. The discovery of cortisone allowed survival of infants with severe CAH for the first time. New hormone tests and karyotypes allowed more confident diagnosis in infancy and prediction of future development. Surgeons began to devise techniques for repairing the abnormalities of the genitalia. Undescended testes could be retrieved, and hypospadias and chordee usually successfully repaired. A greatly enlarged clitoris could be amputated to the usual size, but attempts to create a penis were unsuccessful. John Money and others observed that children with the same types of intersex condition might have been raised as different sexes, and were more likely to develop a gender identity that matched sex of rearing than sex of chromosomes, gonads, or hormones. He also reported that gender identity was usually developed and "set" by early childhood, such that attempts by parents and doctors to reassign sex at an older age was rarely successful. Endocrinologists and surgeons began to base sex assignment in difficult cases not just on the external genitalia, but on the internal genitalia, on the expected future response to testosterone, and on potential fertility. Endocrinology is a branch of medicine dealing with disorders of the endocrine system and its specific secretions called hormones. ... Congenital adrenal hyperplasia (CAH) refers to any of several autosomal recessive diseases resulting from defects in steps of the synthesis of cortisol from cholesterol by the adrenal glands. ... Androgen insensitivity syndrome (AIS, or Androgen resistance syndrome) is a set of disorders of sexual differentiation that results from mutations of the gene encoding the androgen receptor. ... Mixed gonadal dysgenesis refers to a condition of abnormal and asymmetrical gonadal development leading to a disturbed sex differentiation. ... Cortisone is a steroid hormone. ... John William Money, Ph. ...

In the 1960s, surgical confidence with birth defect repair advanced, as did the acceptability and experience with adult sex reassignment surgery. Pediatric surgeons attempted and claimed success with reconstruction of infant genitalia, especially enlargement or construction of vaginas. The view of gender as a purely social construction, and gender identity as a result of "nurture" rather than "nature" reached near-universal acceptance, especially among liberal, progressive, and academic portions of Western society. The primary goal of assignment was to choose the sex that would lead to the least inconsistency between external anatomy and psyche (gender identity). This led to the recommendation that any child without a penis could be raised as a girl, taught to be a girl, and would develop a female gender identity, and that this would be the best way to minimize future discrepancy between psyche and external anatomy in those few biologically male infants unfortunate enough to be born with an irreparably defective penis (e.g., cloacal exstrophy), or to lose it to accidental trauma in early infancy. John Money reported successful reassignment at 22 months of age from male to female of a boy whose penis was destroyed during circumcision. A congenital disorder is a medical condition that is present at birth. ... The vagina, (from Latin, literally sheath or scabbard ) is the tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. ... The word gender describes the state of being male, female, or neither. ... Cloacal exstrophy is a severe birth defect wherein much of the abdominal organs (the bladder and intestines) are exposed. ... It has been suggested that Circumcision advocacy be merged into this article or section. ...

The recommended "rules of assignment" and surgery from the late 1960s until the 1990s were roughly:

• Any XX infant, no matter how virilized, should be raised as a girl to preserve the chance of future fertility. A large, protruding clitoris should be reduced in size with a nerve-sparing recession or reduction rather than simple amputation.
• Any undervirilized XY infant should be raised as a boy if the penis could be expected to be large enough to stand to urinate and to insert into a vagina for coitus. If it was too small or too malformed (e.g., cloacal exstrophy) for these functions, it was recommended that the baby be assigned as female, any gonads removed, a vaginal opening surgically constructed, and estrogen provided at puberty.
• An infant with mixed chromosomes (e.g., mixed gonadal dysgenesis or true hermaphroditism) could be raised either way depending on appearance of genitalia and size of phallus.
• Gender identity is set by 2 years of age and reassignment after that age should not be attempted unless requested by the patient.

These continued to be the most commonly used criteria for assignment until the mid-1990s with one modification. With the recognition in the late 1970s that many cases of micropenis could be treated with hormones, female assignment for unambiguous micropenis went from "recommended but uncommonly done" to "rarely" done. Urination, also called micturition, is the process of disposing urine from the urinary bladder through the urethra to the outside of the body. ... Cloacal exstrophy is a severe birth defect wherein much of the abdominal organs (the bladder and intestines) are exposed. ... Estrogens (also oestrogens) are a group of steroid compounds, named for their importance in the oestrus cycle, functioning as the primary female sex hormone. ... Puberty refers to the process of physical changes by which a childs body becomes an adult body capable of reproduction. ... True hermaphroditism is a medical term for an intersex condition in which a person is born with both ovarian and testicular tissue. ... Micropenis is a medical term that describes an unusually small penis in a human male. ...

In the last decade a number of factors have led to changes in the recommended criteria for assignment and surgery. These factors have included:

• Dozens of grown intersex patients complained publicly about unsatisfactory sexual function or incongruent gender identity, and criticized infant surgery for intersex conditions. Some have suggested that assignments be made more tentatively and surgery deferred in acknowledgement of the possibility of a desire to change gender when the child is older (see Re-assignment, below)

• In 1997, the "rest of" David Reimer's story was made public. He was the boy who had lost his penis to a surgical accident at 8 months in 1966, was reassigned from boy to girl at 18 months with further surgery to remove testes and estrogen treatment beginning at age 12. Although John Money had described the reassignment as a success in the 1970s, Reimer went public with his account of continuing to have a male gender identity despite the reassignment to a female sex of rearing. At age 15, Reimer reverted to living as a male. At age 38, he committed suicide.

• There has been a significant swing in educated opinion back toward the importance of biological factors ("nature") in many aspects of human sexuality.

• A large proportion of XY infants born with cloacal exstrophy and raised as female from early infancy have requested reassignment to male gender in late childhood and adolescence.

Current recommendations for assignment in cases of intersex and other birth defects of the genitalia: For David J. Reimer (politician), see list of candidates David Reimer (August 22, 1965 – May 5, 2004) was a Canadian man who was born as a normal boy, but was sexually reassigned and raised as a girl in an attempt to improve his life after his penis was inadvertently destroyed... Human male anatomy The testicles, known medically as testes (singular testis), are the male generative glands in animals. ... John William Money, Ph. ... Cloacal exstrophy is a severe birth defect wherein much of the abdominal organs (the bladder and intestines) are exposed. ...

• Raise nearly all XX infants with functional ovaries as female.
  • The only rare exception would be completely and unambiguously virilized XX infants with CAH, who might be raised as male with genital surgery deferred.
• Raise most ambiguous XY infants with testes as male unless the external genitalia are more female than male, marked androgen insensitivity is present, and testes are absent or defective.
  • Raise as male any biological male with unambiguous micropenis.
  • Raise as male any XY infant with functional testes and normal androgen sensitivity but malformed or absent penis.
• Raise infants with mixed gonadal tissue, true hermaphroditism, or other chromosomal abnormalities as the sex most consistent with external genitalia, since gonads are usually nonfunctional.
• Gender identity is set by 1-2 years of age and reassignment after that age should not be attempted unless requested by the patient.

Controversies have continued in this decade over surgical aspects of intersex management, especially indications for surgery and optimal timing, but the revised assignment recommendations have been nearly universally accepted. XX can mean more than one thing: For the Roman numeral XX, see 20 (number) For XX chromosomes, see XY sex-determination system See also XXXX, XXX, X This is a disambiguation page — a navigational aid which lists other pages that might otherwise share the same title. ... Congenital adrenal hyperplasia (CAH) refers to any of several autosomal recessive diseases resulting from defects in steps of the synthesis of cortisol from cholesterol by the adrenal glands. ... XY may refer to: coordinates, see cartesian coordinate system XY sex-determination system XY Magazine, a gay youth-oriented magazine published in the U.S. X&Y, an album by Coldplay XY Website, a personals website hosted by XY Magazine, intended for young gay, bi, and lesbian youth aged 13...

Re-assignment of sex or gender

Sex reassignment refers to a change of sex/gender after an original and presumably definitive assignment in infancy. This unusual event can occur in several circumstances.

1. An early reassignment may be made to correct a clear error. The most common example of this is when a newborn is assumed to be a boy and assigned as such despite absent testes. If at 1-4 weeks of age it is discovered because of newborn screening, a salt-wasting crisis, or investigation of the cryptorchidism that "he" has ovaries, uterus, an XX karyotype, and CAH, the child is likely to be reassigned as female. When virilization is complete and unambiguous, reassignment may be declined or deferred. Any reassignment after the first month or two is no longer considered an "early reassignment".
2. There have been cases where a male infant has been reassigned to female at several days, weeks, or months of age because of an irreparable birth defect of the genitalia or loss of the penis to trauma or other accident. This is no longer recommended by most experts in the field because of the publicity surrounding similar failed reassignments in the 1990s.
3. There have been rare cases where a child with an intersex condition has rejected a sex of rearing, asserted an opposite gender identity, and requested reassignment. Examples of this have occurred in adolescents with several forms of CAH and 5-alpha-reductase deficiency.
4. The most common type of reassignment occurs when a child or adult with no detectable intersex condition rejects the sex of rearing, claims an opposite gender identity, and either requests or asserts a new gender. Such a person is described as transgendered or transsexual. Surgery to align their body with their gender identity is usually performed in adulthood and referred to as sex reassignment surgery.
5. One case was with a pair of male ischiopagus conjoined twins who shared one set of male genitalia. On surgical separation, one twin received the male genitalia and the other twin was surgically feminized.

Karyogram of human male A karyotype is the complete set of all chromosomes of a cell of any living organism. ... Congenital adrenal hyperplasia (CAH) refers to any of several autosomal recessive diseases resulting from defects in steps of the synthesis of cortisol from cholesterol by the adrenal glands. ... 5-alpha-reductase deficiency (5-ARD) is a condition caused by a mutation of the 5-alpha reductase type 2 gene. ... Transgender is an overarching term applied to a variety of individuals, behaviors, and groups involving tendencies that diverge from the gender role (woman or man) commonly, but not always, assigned at birth. ... A transsexual (sometimes transexual) person establishes a permanent identity with the opposite gender to their assigned (usually at birth) sex. ... Sex reassignment surgery (SRS) includes the surgical procedures by which a persons physical appearance and function of their existing sexual characteristics are changed to that of the other sex. ... Modern, healthy, living 15-year-old conjoined twins Abigail and Brittany Hensel. ...

See also

• Sexual differentiation
• Intersexual
• List of transgender-related topics
• History of intersex surgery for a more detailed history of the evolution of medical management of intersex conditions, with a more extensive list of references.

Sexual differentiation is the process of development of the differences between males and females from an undifferentiated zygote (fertilized egg). ... An intersexual or intersex person (or animal of any unisexual species) is one who is born with genitalia and/or secondary sexual characteristics of indeterminate sex, or which combine features of both sexes. ... Transgender is a very complex topic, where consensual and precise definitions have not yet been reached. ... Intersex surgery is one of several terms referring to surgery performed to correct birth defects due to intersex conditions or other causes, as well as early injuries of the genitalia. ...

External links

• Page containing images from a sex-change procedure
• The Ciba Collection of Medical Illustrations: Vol.2, Reproductive System by Frank H. Netter, M.D. comparing female and male reproductive systems development and anatomy
• Development of the Female Sexual & Reproductive Organs – illustrations comparing female and male genitalia during the early development
• "Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth" by William G. Reiner, M.D., and John P. Gearhart, M.D. in the NEJM, Volume 350:333-341January 22, 2004 Number 4
• Genes may trump nurture with intersex kids - an article about this study.
• Sexual identity and sexual orientation in children with traumatized or ambiguous genitalia by Milton Diamond, Journal of Sex Research, Spring 1997.