Between The Sexes

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AMBIGUOUS: Elijah developed both male and female features. In January he had his ovaries surgically removed

In 1993 Debbie Hartman was sure she was hearing things in her hospital room. She had just undergone a caesarean section, and the doctors were saying the baby was healthy but they weren't sure whether it was a boy or a girl. "I thought the drugs were making me hallucinate," she recalls. In fact, she was hearing just fine. But nothing about her child's biology — from the chromosomes to the reproductive tissue — conformed to the standard demarcations we have come to expect between the male and female sexes. In the language of developmental biologists, the baby was "intersexual."

Careful examination showed that the infant had one testis, what looked like a small penis and no uterus or vagina. Genetic tests did not make things any clearer: some of the child's cells contained the XX chromosome pairing typically seen in girls, others contained the XY pattern seen in boys, and some had but a single X chromosome, commonly seen in girls with a condition called Turner syndrome.

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Technically speaking, the Hartman baby was a true hermaphrodite. Scientists don't know how this happens, but one possible explanation is that two eggs are fertilized in the womb — one XX and the other XY — but rather than developing separately into twins, the zygotes merge to become one embryo. At any rate, "hermaphrodite" is not one of the options available on a birth certificate, so the Hartmans' doctors struggled to figure out which sex was more appropriate for the child. Meanwhile, Debbie's sister and mother told relatives and friends not to send anything pink or blue. "They said yellow or green," Hartman recalls. "Or better yet, just send a card."

After two weeks, the doctors decided the baby was a boy. Debbie and her husband — they have since divorced — named their son Kyle and took him home. Debbie quickly dubbed her little guy Mr. Man and Slugger. When Kyle was 11 weeks old, however, he developed a hernia that required surgery. Midway through the operation, four doctors came to the waiting room, and one of them told Kyle's parents that "your child is in fact a girl." The surgical team had found rudimentary ovarian and Fallopian-tube tissue in Kyle's body.

In some ways, this latest turn of events was even more upsetting and confusing than the birth. But the physician's recommendation was clear: the vestigial ovarian and Fallopian-tube tissue and the testis should be removed at once, while the child was still under anesthesia. Otherwise the tissue could become cancerous. "All I could hear was cancer, cancer, cancer," Debbie says. So she and her husband consented to the operation. (The phallus, which doctors eventually renamed a clitoris, was surgically reduced two years later.) The next day the Hartmans took home their recovering infant, whom they quickly renamed Kelli. The family held a second baby shower, and boyish clothing was replaced with lacy pink dresses and other feminine attire.

Kelli went on to have three more surgeries to construct female-looking genitalia. But the matter wasn't settled. At the age of 4, she started asking, "Mommy, am I a boy or a girl?" When she was 6, she questioned her mother about all her surgical scars, and when Kelli was 8, her mother told her the whole story.

The truth came as a relief, although Kelli, now 10, is still grappling with the significance of gender in her life. A stocky, surefooted kid whose interests range from gardening and landscaping to marble collecting and woodworking, Kelli suffers from attention-deficit/hyperactivity disorder, which, she says, actually makes her feel more self-conscious than being intersexual. When asked what she wants to be when she grows up, she replies, "A carpenter. Maybe I'll be a male carpenter." Why a male carpenter? "Because I'd be taken more seriously."

True hermaphrodites like Kelli are thought to be quite rare. But less extreme cases of intersexuality occur more often than you might think. One estimate from a scientific review published in 2000 is that they represent 0.2% to 2% of live births. About 30 genetic and hormonal conditions can give rise to intersexuality, leading, in some folks, to an obvious mixture of male and female sex traits. In others the variation is far less noticeable, producing, for example, the premature development of body hair. Indeed, many intersexuals probably live their whole lives as men or women without ever suspecting the complexity of their nature.

For years doctors believed that the best treatment for an obviously intersexual newborn was a swift one. The reproductive system and genitalia were surgically refashioned to conform to one sex or the other. (In practice, this often meant deciding that the child should be a girl because, in the indelicate phrasing of the surgical world, "it's easier to make a hole than build a pole.") The goal was to minimize the amount of time the child spent with a nonstandard body in the hope that he or she would find it easier to develop a conventional sense of gender. As in Kelli's case, there was also concern that "extraneous" reproductive tissues might be more likely to become malignant.

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