Letter from The Dominican Republic — From the August 2017 issue

Sons and Daughters

The village where girls turn into boys

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In the United States, we would refer to Anaibe, who is now twenty-seven, as intersex. In other words, she was born with reproductive or sexual anatomy that did not fit the binary notion of biologically male or female but instead fell somewhere along a spectrum between the two.

Medically, intersex is referred to as a disorder of sexual development — although the appropriateness of such pathologizing language is disputed by intersex activists. There are more than twenty kinds of D.S.D.’s, but the type prevalent in Las Salinas and Saladillo is called a 5-alpha-reductase deficiency. In such cases, a lack of dihydrotestosterone production in the womb causes children who are genetically male to be born with what looks like a vagina: that is, the scrotum resembles labia, and usually the testes are, for the moment, internal. There is also a clitoris-like phallus, sometimes called a micropenis. Not surprisingly, these children are often raised as girls — until the onset of puberty. At that point, as a second wave of testosterone surges through the body, their testicles descend, their penises may grow, and they begin physically to look like men.

For decades, the accepted wisdom in the United States has been to surgically alter the genitals of intersex babies at birth, essentially allowing doctors and parents to decide on the child’s “true” sex. Once 5-alpha is diagnosed, for example, many American doctors recommend lowering the testes and changing the position of the urethra (which tends to be in the middle of the micropenis, as opposed to on the end). Laurence Baskin, the chief of pediatric urology at the University of California, San Francisco, told me that he would recommend early surgery not just for 5-alpha but for 95 percent of known D.S.D. conditions.1 (He stresses, however, that the final decision is always made by the parents.) Baskin classifies such operations as corrective surgeries, no different from fixing a cleft palate or clubfoot. “We basically treat them because they have a congenital anomaly,” he told me. “The goal is for them to have a successful life.”

1 In the remaining 5 percent of D.S.D. conditions, Baskin argues, it is too hard to figure out how the child will ultimately identify — and so he is reluctant to recommend surgery. These conditions include ovotesticular disorder, which causes babies to be born with both ovarian and testicular tissue. (It was previously referred to as true hermaphroditism, while 5-alpha had been called pseudohermaphroditism.) Ovotesticular disorder made headlines in 2015 after the parents of a child identified as M.C. sued the hospital and state guardians who had approved their adopted son’s sex-assignment surgery. When M.C. was sixteen months old, doctors removed his two-centimeter penis and undescended left testicle to give his genitals the appearance of a vagina — but as M.C. grew older, he began to identify as male. His parents insisted that the choice should have been left up to him, and initiated the first public court case of its kind.

Baskin, who has been practicing for twenty-five years, explained that the medical community has long-term data on children who underwent such procedures. He has tracked his own former patients well into adulthood and reports that they are now “successful, fully functioning members of society.”

But a growing number of intersex activists and families have come to oppose early surgery, viewing it as nonconsensual, mentally harmful in the long term, and ultimately unnecessary. Instead they advocate leaving the children alone, allowing them to make their own decisions about surgery later in life. Nobody is suggesting that surgery is never appropriate, or that the doctors in question are “inherently evil people,” said Georgiann Davis, an assistant professor of sociology at the University of Nevada, Las Vegas, and an intersex activist. “They’re trying to help. But if you frame something as a medical problem, then you’re establishing the need for a medical response.”

On the face of it, there is a compelling argument for stopping surgical intervention: Why make lifelong decisions for children before they are even able to speak? At the same time, many parents feel a desire to ease their child’s life — to smooth the road ahead, to avoid potentially painful confusions and conversations. All parties want the same outcome for adulthood: fulfillment, respect, a partner or family (if those things are desired). Where they differ is in how to get there. After all, while many of us are quick to endorse inclusivity as a bedrock principle, our society is still rigid when it comes to the construction of gender. We struggle with difference. The first question when a baby is born tends to be: Is everyone healthy? The second is: Is it a boy or a girl?

One of the issues that surfaces again and again in the debate over early surgery is that we don’t know enough about intersex babies who grow up without intervention. There simply aren’t sufficient case studies to answer many of the most basic questions. Would such people regret not having had surgery? Would they be happier? Would it be easier if they grew up in a culture that was more flexible in its view of gender roles? What would society look like if intersex people were much more common, and if most intersex children were allowed to make their own decisions about their identity?

Anaibe’s hometown may help to answer some of these questions. In the United States, the exact prevalence of intersex births is disputed, but a conservative estimate would place the number at one in two thousand. In Las Salinas and Saladillo, one in ninety children is born intersex, making the community a kind of laboratory of gender fluidity, with a surprising range of outcomes.

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