Letter from The Dominican Republic — From the August 2017 issue

Sons and Daughters

The village where girls turn into boys

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Felicita Carrasco was born in a slatted wooden house in a village so small it doesn’t appear on maps of the Dominican Republic. Saladillo, with its single paved road, is essentially a subdivision of Las Salinas, a larger town of six thousand. The two isolated communities sit on the cusp of a mountain ridge covered with Creolean pines that stretches almost to the border with Haiti.

The family’s third child, Felicita had light skin, electric hazel eyes, and a head of dark curls flecked with blond. Most of this she inherited from her mother, Claribel, who loved Felicita’s thick hair and spent hours brushing it, styling it, affixing bows. Growing up, the little girl — who was nicknamed Anaibe — often played in the yard with her older sister, Angelina. Their favorite game was choosing names for their future children: especially their sons. Together they cleaned the house, washed dishes, and went to neighborhood birthday parties.

All photographs from the Dominican Republic by Nadia Shira Cohen

In time, though, Anaibe’s behavior began to change. She preferred pants to skirts, and took to pulling Claribel’s ornate pink-and-white bows out of her hair. She sneaked out to play with the neighborhood boys, who spent their time caked in mud, racing rickety cars they had made out of wooden planks, climbing trees, and throwing rocks at birds.

Claribel was always looking for Anaibe around the village, yanking her away from the gaggle of boys, and dragging her home. “Play with the girls!” she told her daughter. Anaibe would stomp her feet and sulk in the back yard with the family’s wandering chickens and its pack of tiny, pointy-eared dogs. When enough time had passed, however, she would escape again.

For her part, Anaibe didn’t know how to explain this confusion, not that anyone ever asked. Things just didn’t feel right. Her older sister’s frame began to take on feminine contours — rounded hips, the suggestion of breasts — but Anaibe’s never did. One night, when Anaibe was twelve, she woke Angelina in the bed they shared. She had been touching her vagina when she noticed something. “I feel like I have two balls inside there,” she whispered. “I don’t know if it’s an infection or what.”

Angelina did a quick inspection. “I don’t know what it is, either,” she said. “Mine isn’t the same.”

Over the next year, Anaibe grew stronger and taller than her sisters. Her chest expanded, her shoulders broadened. There was a ripple in her throat, and when she flexed her muscles, her friends were impressed. In the schoolyard, some of the kids started to tease her, and when she couldn’t bear it any longer, she hit them — often joined by her five brothers and sisters, an entire squad of Carrascos dispensing vigilante justice. But the kids kept at it. They called her guabidó, güevote, machihembra. And while the words stung, they also resonated.

Everyone in Las Salinas and Saladillo has heard of guabidós, güevotes, and machihembras: children born as girls who grow into men. Cases are common enough that many can point to a guabidó in their extended family. Claribel was familiar with the words. Still, that didn’t mean she could look at her daughter and instantly figure out what was going on — or that she wanted to.

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.

During the week, the heat seems to cast a languid spell over Las Salinas. In the morning, children in neatly pressed blue uniforms make their way to school. They walk past two-room houses made of concrete and wood and through the central square, where a bust of Juan Pablo Duarte, one of the country’s founders, stands watch. Every few blocks, there is a colmado, a small corner shop selling plantain chips and soda. The town’s morning market has become smaller over the years, but half a dozen stalls still stock fruits and vegetables — sweet potatoes, taros, and avocados — and Haitian migrants sell secondhand clothes in piles on the side of the road until noon.

At dusk, when the heat breaks, sunsets of purple and fluorescent pink streak the sky, and groups of neighbors begin to cluster outside, watching others pass, calling out greetings. It feels like everyone knows everyone, and is somehow related — usually as a primo, or cousin. The feeling of one great extended family promotes both warmth and a lively gossip mill. As the locals put it: Pueblo pequeño, infierno grande. Small town, big hell.

On the weekends, everything changes. The town pumps with bass, sweat, and booze. It is by far the loudest place I have ever been. Competing bars, each with its own sound system, blast bachata into the central square. Many of the men have spent the earlier part of the day gambling at cockfights, and now, as the entire town gathers outdoors to drink beer and rum out of small plastic cups, they recount the matches once again. At midnight, a Mitsubishi truck with a speaker system on the roof is still parked in front of Duarte’s bust, thumping beats into the darkness, and everyone, from tiny toddlers to grandmothers, dances on the pavement.

Most residents of Las Salinas spend hours preening for this weekly event. Women get their hair done, men do the same. Each beauty parlor buzzes with gossip about the town’s romantic and erotic entanglements — a reminder that sexuality is anything but a forbidden topic.

“The first girlfriend of every Dominican boy is his hand,” Yessika Terrero, a twenty-two-year-old who has an infant daughter herself, told me on a Saturday night. Her friends nodded sagely as we sat in a group on a curb. Terrero badly wanted to take me for a spin on her friend’s motorcycle. As she navigated through the square, she slowed just enough to make sure that all the men who saw us could let loose a long catcall.

Las Salinas was founded in 1730 when Juan Féliz de Luna, a Spanish colonist, lost track of his cows. He found his herd in the mountains, licking a rock. He tried it himself, tasted salt — and three Spanish families soon thrived in the new trading post, which they named for the mineral. According to a local history professor, Abraham Terrero, by 1932 the population had reached about two thousand. That same year, Rafael Trujillo’s government seized the territory for industrialization, building facilities to extract salt and gypsum and simultaneously destroying the local economy. Poverty remains widespread, as do water shortages and electricity cuts, which explains why young people have been abandoning Las Salinas in increasing numbers for decades.

While the cows have supplied the place with its creation myth, there is none for the prevalence of 5-alpha. “This is a phenomenon as old as the town itself,” Miguel Gómez, one of the four Evangelical ministers in Las Salinas, explained. “It’s in the town’s soul.” There are scattered speculations about the origin of the condition: spiritual punishment for ancestral incest, the ingestion of iodine in the unprocessed salt from the mine. But mostly, people told me they didn’t know why it happened. God simply made them that way, they said, and that was that.

Outsiders have been more intent on finding an explanation. In 1972, a Dominican-born doctor named Teófilo Gautier came to Las Salinas to investigate what was then referred to as the “underlying etiology of pseudo-hermaphroditism.” Working in conjunction with a team from Cornell University led by Julianne Imperato-McGinley, Gautier hired local nurses to assist him, but they had difficulty persuading people with intersex children to participate in the study.

“They were uncomfortable at the beginning,” said Reyna Cuevas, a nurse who assisted Gautier. “Some asked, ‘What good will you bring us?’ ” Many of the children themselves were even more reluctant to talk. “Most of them felt lost,” Cuevas told me. “They did not know who they really were.”

Gautier continued to collect data, and he later opened a clinic devoted to “genital ambiguity” at the Robert Reid Cabral Children’s Hospital in Santo Domingo. The group published its research in The New England Journal of Medicine in 1979. Imperato-McGinley and her team declared that 5-alpha was a genetic mutation: a recessive trait, probably the result of pervasive intermarriage. Between Saladillo and Las Salinas, researchers had discovered thirty-eight cases in twenty-three interrelated families, spanning four generations. Roughly half had been unambiguously raised as girls. Of the eighteen subjects that researchers were able to interview, all but one had changed to a male gender identity during or after puberty, and most were living with female partners. They were infertile, but many were raising children from their partners’ previous unions.

The researchers noted that while the communities had strict gender norms, nature appeared to trump nurture. That is, while many of the subjects had been raised as girls, once puberty set it, they were accepted as boys. They were, the researchers wrote, a “testimonial to the malleability of human beings in the acquisition of gender identity” — quite a novel conclusion back in the Seventies.

2 In Papua New Guinea, members of the Sambia tribe with 5-alpha are viewed as a third gender, called kwolu-aatmwol. Gilbert Herdt, an anthropology professor at San Francisco State University, identified fourteen intersex individuals among the Sambia. Five had been raised as females, the rest as kwolu-aatmwol, which is roughly translated as “male-like-thing into masculinity.” The tribe had strict gender norms, and there was suspicion among the men that women killed intersex infants at birth. While a few kwolu-aatmwol had risen to distinction through special achievements, most were “treated ambiguously and somewhat stigmatized due to their condition,” Herdt wrote in a 1988 paper published in Archives of Sexual Behavior. They were rarely given wives. “Why waste a good fertile woman on a hermaphrodite?” Herdt was often told.

Las Salinas and Saladillo are exceptional in another way too. High incidence of 5-alpha has been discovered in two other locations: villages in Papua New Guinea and Turkey. In those places, however, the individuals undergoing transition are to some degree ostracized.2 But in Las Salinas and Saladillo, those with 5-alpha are accepted with relatively few qualms. “Parental attitudes during the course of the change involved amazement, confusion, and finally acceptance rather than hostility and prevention,” the researchers wrote. The Dominican Republic is traditionally regarded as a patriarchal island brimming with machismo — where, indeed, a recent U.S. ambassador was publicly vilified for bringing his husband to his posting. It was, and is, an unlikely place to find an enclave of acceptance. So what explains this unique tolerance?

There wasn’t a specific moment when Anaibe realized what was happening. Instead, it was more like a steady accumulation of knowledge. She heard things in the neighborhood, she heard things at school, she began to realize that there were other people like her in the community — and they were men. Could she be one of them?

Her first victory was underwear. One day when Anaibe was twelve, Claribel went to Barahona, a city an hour away, and bought some clothing for her children. When she returned with new panties for Anaibe, her brothers thought it was the funniest thing they had ever seen. “She doesn’t want that!” they cried. “Come look, Anaibe! Mommy bought you some panties!” Refusing to wear them, she demanded boys’ underwear instead, and her mother eventually obliged, buying Anaibe two pairs, one red, one green.

Three years later, Anaibe asked a woman who cleaned the school to cut off her hair. When she came home, the family was shocked. “I’d never seen someone like that,” Angelina recalled. “I thought that we were four girls in the house. I thought he was a girl.” Soon after, Anaibe also switched bedrooms, moving in with the boys.

No one said anything. Claribel let it go. She was more concerned that Anaibe would never find a partner. “I used to sit down right here,” she told me, as we sat under a leafy tree in the front yard. “If I didn’t have a book to read, I took a puzzle book and did a puzzle.” But these activities seldom distracted her for long. “I felt bad that I thought he was a girl. When I realized he was a boy, I felt bad about that too. Mothers always feel guilty.”

By now, Anaibe had grown to be tall, broad-shouldered, and almost unbearably handsome. Women found him irresistible, flirting when he visited Santo Domingo, asking his cousins why he was so quiet. Why wasn’t he hitting on them, when they so obviously wanted him to?

In Las Salinas too, his insecurities got in the way. When he was sixteen, Anaibe fell in love with a girl who initially seemed amenable to his advances. She was his first formal girlfriend — until she decided to date someone else. In a letter, she explained that she had seen Anaibe talking to another girl and found his behavior unacceptable. But he thought she was lying: He was sure that his condition had gotten in the way. For three days he felt suicidal, until his brothers intervened. “Forget about that woman,” they told him. “There are a lot of them in the world.” Eventually he did. Like the other teenagers in Saladillo, he got into the habit of creeping around the village’s dark patios at night, kissing the girls who admired him. But if things went any further, the fear crept in again.

At eighteen, he asked his family and friends to call him Johnny. That same year, he was at the sole bar in Saladillo, drinking with friends. Revelers jammed the small room, crowding the pool table and spilling out onto the packed-dirt patio overlooking a small stream. Late in the evening, when the crowds had faded and Johnny was buzzed, he decided to try something he had been thinking about for a while. He waited until the coast was clear and headed for the bathrooms. He entered the men’s room for the first time and locked the metal door. This was what he had wanted. This felt right.

The first thing that crossed my mind was: Oh, my God, I don’t want to imagine I have a kid like this,” Gabriela Pérez told me about the day her daughter was diagnosed. At the time, Gaudelin was four months old. She had a fever and Pérez, who goes by the nickname Juliana, brought her to the hospital. When the pediatrician performed a general exam, the baby’s genitals made her pause.

“Have you seen this?” the doctor asked. “Have you taken a careful look?”

Juliana shrugged. When Gaudelin was born, Juliana noticed that her vagina seemed inflamed, but when she asked the obstetrician whether there was anything abnormal, she got no answer, and didn’t give it further thought.

“Something isn’t right here,” Juliana remembered the pediatrician telling her. We were sitting in her pink one-room house, with the lace curtain that divided the sleeping quarters from the kitchen fluttering from the breeze of the fan. “We need to order a sonogram.” Soon the technician showed Juliana her daughter’s anatomy on a screen, where a single testicle was visible. Juliana was shaken. “I didn’t want my child to go through that.”

As she shuffled from one exam room to another, Juliana ran into her best friend in the hospital corridor. When she explained what was happening, she admitted her feelings and wondered if God was delivering a castigo: a punishment. Her friend dismissed the idea. “The next year my friend had a baby with the same condition,” Juliana told me, and paused meaningfully.

For the first year after the diagnosis, Juliana cried constantly. She stopped eating. Her mother had let the tale slip, and word got out in the town. “I felt the people talking, talking, talking, gossiping about me,” Juliana explained. “But no one spoke directly to me.”

Today, Gaudelin is an adorable, rambunctious five-year-old with big eyes, a loud giggle, and more energy than Juliana knows what to do with. She is effectively the family’s alarm clock, rising before six every morning and waking her mother and older sister. After the two girls bathe in a large vat in the back yard, Juliana braids their hair and sends them to school together. When she’s not at preschool, Gaudelin spends most of her time in a child-size dollhouse, primarily in the tiny kitchen, where she pretends to cook, mixing mud in pots and making a mess. She also loves dolls, brushing their hair with such ardor that they often end up bald. “She only likes girls’ games,” Juliana kept emphasizing when we spoke.

The doctors told Juliana that Gaudelin needed more tests, including a karyotype, which analyzes the size, shape, and number of a patient’s chromosomes. For her part, Juliana wants Gaudelin to have surgery that would lock in her female identity, and as soon as possible. Her best friend’s daughter, who Juliana told me had two testicles, had already undergone such surgery. “In my case,” Juliana told me, “it’s only one testicle and no penis. If that one got the surgery with two testicles, why not mine?”

Since most intersex children in the community have eventually transitioned to a male identity, I was curious as to why Juliana continued to raise her child as a girl — and also why she wanted to have surgery performed so quickly. She knew a fair amount about 5-alpha. Unlike some of the other mothers I spoke with, who had never taken their children to a doctor before the onset of puberty, Juliana brought Gaudelin to a specialist in Santo Domingo every six months. She had seen the testicle on the screen and discussed it with a doctor many times.

“What makes you dress her like a girl when most cases are boys?” I asked.

“Well,” Juliana said, laughing, “I don’t know what to say. There are some people who tell me that she has a boy’s face.”

“What do you think?”

“I don’t think anything,” she said. “Because for me, she is a baby girl.”

Next year, Gaudelin will start elementary school with a teacher who has two children with 5-alpha. When the oldest was born, she dressed him as a girl for two weeks until Gautier, who was still working in the community at the time, suggested male clothing instead. The teacher (who asked not to be identified) initially found the idea hard to accept. And indeed, according to William Reiner, a former urologist and child psychiatrist at the University of Oklahoma College of Medicine, it is usually the parents who have a harder time dealing with transition, as opposed to the children themselves or their siblings and friends. In any case, the teacher soon adjusted.

I asked Juliana whether she had ever thought of talking to the teacher about Gaudelin’s potential difficulties, including schoolyard bullying. She had, after all, been through this process not once, but twice. Juliana said no.

“It’s a shame for me,” she said. “I don’t want to ask. The same way I don’t want people to ask me.”

Don José’s grave is one of the largest in the Las Salinas cemetery. The teal-painted family tomb stands amid more modest graves with wrought-iron and cement crosses along dirt tracks lined with parched shrubs. Confesor Terrero, a slender laborer in a baseball cap who happened to be digging a grave on the afternoon of my visit, took me into the inner chamber of Don José’s mausoleum. “He was a very good leader,” he said. “The right hand of Balaguer.”

After Trujillo was assassinated in 1961, Joaquín Balaguer served several nonconsecutive terms as the country’s U.S.-backed president. During his second stint in office, from 1966 to 1978, Don José (whose given name was Thermio Cuevas Pérez) led the president’s Partido Reformista Social Cristiano in Las Salinas. At a time when politics in the country ran on favors and connections, this made him the town’s unofficial mayor for twelve years. “He was a hard-working man,” Terrero told me. “He gave a lot of jobs to the people. He had the biggest warehouse in town.” And then Terrero announced: “He was what you know today as a güevote!”

How did Terrero know? “He lived with my aunt. He maintained her very well: the house, food, everything a woman wants. Except children.” When I asked whether anyone ever spoke to Don José about his condition, Terrero laughed. “No! He was a very strong man and he always carried a gun. Nobody could tell him that!” He paused. “But this is a tiny town, everything is known.”

During my time in Las Salinas, I heard a lot about Don José: He was not too tall, not too short, average height, solidly built, with dark skin. He dressed well, in suits and a hat. He liked beer. He was funny. He was a womanizer — he stole many women from their homes. He loaned money to everyone who asked, even when he knew they wouldn’t be able to pay him back. Through his friendship with Balaguer, he received funds to build houses, roads, and the town’s only high school. (The president showed up for the opening ceremony.)

During his second term, Balaguer developed a penchant for authoritarianism, and political opponents were thrown in jail at the whim of the president and his local representatives. Now Don José became even more essential to the community, bailing out townspeople from opposing parties and lecturing them as if they were naughty schoolchildren. He helped Andrés Cuevas, a lawyer and politician, out of jail several times. “Even though he was on the other side, I have a lot of respect for him,” Cuevas told me. “He was a great man.”

I first heard about Don José from a group of local politicians, when I was sitting on the porch with the town’s mayor, Genris Encarnación, and various other dignitaries, including the vice mayor and the director of the local clinic. “Don José!” the group shouted, almost in unison. “He was with five women! He took five women from their homes!”

“So his condition didn’t stop him from being a playboy?” I asked.

“No, because he had the energy to be a real man,” said Yenny Terrero, the vice mayor.

“That kind of person will get married. When they cannot do things in one way, they find another way to do it,” Encarnación added.

If I can do nothing from here to here,” said Regil Terrero, another member of the administration, gesturing to his groin, “I can do it with my mouth.”

Everyone chuckled at this paean to Don José’s virility, which seemed to reflect the prevailing machismo of the town while making allowances for differing technical means. In fact, Don José was rumored to have multiple sexual strategies, according to Luis Concepción, who had been mayor of Las Salinas for ten years before losing the most recent election a month earlier. When we spoke, Concepción couldn’t contain himself. Completely unsolicited, he told me everything about Don José’s two penile prostheses.

“He used to have a ribbon around him, and with one part of the ribbon he made his penis erect, and when he wanted to have it go back down, he pulled the other part of the ribbon,” Concepción said. Squat and muscular, the former mayor jumped up, gesturing with his hands and pulling up his shirt to show where the ribbon would have gone, as well as the placement of the two penile prostheses, one black and one white. “He used to switch! Sometimes he used one member, sometimes another,” Concepción told me, raising and lowering his arms to mimic an erection.

His tone reflected the way the community most often spoke about the condition, with a sort of accepting wonder. Of course, they said whatever they felt like saying behind people’s backs, and they did gossip like crazy — Pueblo pequeño, infierno grande — but they did so jovially, without any trace of malice that I could detect. One Saturday afternoon, I dropped by the most popular barbershop in town. The hole in the wall was buzzing, literally. The small blue chalkboard where customers put down their names was full, and men lined the single long bench, with the overflow standing in the corners.

Sex was far and away the most prevalent topic of conversation. “Men and women cheat,” said one of the two young barbers, who was wearing a Boston Red Sox hat and a matching red polo shirt. “But women do it more than men. Women like to have sex.”

Marcos Cuevas, a stout local politician with bright green eyes, waltzed in. After he interrogated me about Donald Trump, I asked him about Don José.

“He was really the head of the neighborhood,” Cuevas said theatrically. For a moment, the room was quiet except for the thrum of the razors. “Don José counseled the people. Don José was a hermaphrodite,” he said, using the term that the townspeople regard as more respectful than güevote or guabidó.

“What is a hermaphrodite?” a man asked.

“It’s a man who has a penis and a vagina. Someone who is a man, who is dressed like a woman,” Cuevas said, a little confusingly. “Where a woman has a clitoris, they have a penis.”

“It’s the same as being gay?” somebody piped up.

“No, some hermaphrodites are men, some hermaphrodites are women. They have a woman’s body, they have boobs. Some of them are female and they have strong female energy. Some have male energy. They behave more like men,” he said.

“But there are some who have both?” asked another man. Cuevas nodded sagely.

“How do people treat them?” I asked.

“Good, normally,” Cuevas told me.

I asked Cuevas how he would feel if his daughter married someone with 5-alpha. He seemed puzzled that I would even ask. “Good,” he assured me. “For me, it’s okay. They can’t have babies, and they have a tiny penis, but it works. It’s not the same as a normal man’s, but they can do some tickling.”

This was not, as I learned, an unusual conversation. Considering the high incidence of 5-alpha in Las Salinas, there was a remarkable amount of misinformation floating around the town, along with a genuine curiosity about the condition. There were those who envisioned the güevotes as centaurs of a kind, equally split between male and female, able to choose their gender at will. Others believed that their energy chose for them. Some, like Juliana, still wondered whether the condition was a curse. Yet in all these cases, those with 5-alpha were considered part of the community, and nobody I spoke to wanted it otherwise.

Every afternoon, Francisco Ramírez, an eighty-five-year-old retired miner, pushes his wife’s wheelchair onto the sidewalk in front of their house and pulls up a plastic chair beside her. The couple have been together for more than fifty years and raised her sister’s children as their own. Ramírez oversaw the construction of the house they live in, working the morning shift at the mine and spending the evenings on his small plot of farmland.

His wife is sick now, her legs are swollen, and her mind often wanders between past and present. As we talked, I noticed that he reflexively caressed her knee when answering questions. I thought it was one of the purest expressions of love I had seen, and Ramírez agreed: he was a romantic. “She has been a great, great woman,” he told me. “She accepted me from the very beginning the way I am, and after finding out about my situation, she didn’t change.”

For his part, Ramírez had no regrets. He had been invited to participate in Gautier’s study, but refused. His friends knew about the condition, he said, but they never spoke about it to him. “Maybe somebody talked about me behind my back. But the people who are talking behind the backs of other people, they are talking with no one.”

There was something puzzling about this code of silence as a form of social delicacy. Despite the town’s furious gossip mill, people seldom spoke directly to those with 5-alpha about their experiences. It struck me as one part shame, two parts respect. I wasn’t the first journalist to come to town, and while the inhabitants of Las Salinas were used to being interviewed, it seemed strange that they would speak to strangers about their intimate lives while declining to have the same conversations with one another, even within families. Everyone told me it was because no one asked.

In Las Salinas, there is another interesting litmus test when it comes to gender fluidity (and its acceptance): Kirsis Ramírez, the town’s sole trans woman. Ramírez started wearing dresses when she was nine. At school she encountered lots of problems from the other kids, who called her names. Yet she, too, was eventually accepted by the townspeople, who repeatedly told me I would never have known that she was transgender. (I got a lengthy lecture from my driver about what made her attractive to men: thick legs, nice butt, nice eyes, always put together.) Ramírez had boyfriends and brought them to the central square on the weekends, and nobody in Las Salinas ever harassed her. Her mother worried more for her outside town, particularly in Santo Domingo, where trans women have been killed in “love motels” and attacked on the street.

Children bullied other children, as has always been the case. The bullying seemed to intensify as the children began to shift in appearance from their initial gender role, which is to say, during puberty. But once they made the transition, they were once again accepted. It was almost as if the uncertainty, the gray zone between genders, was more profoundly disturbing to the community than the transformation of the nominally female into the biologically male.

What was it about Las Salinas? I asked everyone I met. Were they more comfortable with gender fluidity having seen it all their lives?

At the town’s baseball stadium, a concrete behemoth that seemed as big as Las Salinas itself, the players were resoundingly male. They ribbed one another about race, class, laziness — but not about homosexuality or 5-alpha. Esmeraldo Féliz, a portly policeman whose wisecracks had everyone doubled over with laughter, explained: “It doesn’t matter if you’re male, female, homosexual, whatever it is. In the countryside, we are all family.”

Although 5-alpha children who remained women into adulthood were far more rare, they, too, were accepted into the family. When I spoke with Yosemi Ruiz, she had just undergone surgery for breast implants. She had always felt female, even when her parents, heeding Gautier’s advice, had attempted to dress her as a boy. Today she lives with a male partner and is active in her church group. I asked if she thought that gender identity was tied to sexual anatomy, or whether it came from some other source. She answered without hesitation: “It comes from inside.”

I met Johnny in the capital. He had been living at his cousin’s house for almost three months after a doctor saw him on television and offered to perform surgery for free. He had undergone two operations so far and was awaiting clearance to go home. Johnny had many questions: Would his penis get bigger? Would he be able to have children? Did he need additional hormones? He was afraid to ask, his cousin told me, because he didn’t want to jeopardize the free treatment he was receiving.

Back home, his family was eagerly awaiting the answers. Neighbors dropped by to ask how he was faring. In Santo Domingo, Johnny ached for the countryside, where everyone knew him and it was easier to find farm and construction work. He hated showing his government I.D. card, which still featured his female name and prompted embarrassing and irritating questions.

Doctors say that if surgery is performed in the first year of life, children with 5-alpha can maintain male reproductive function. This did seem like one argument in favor of early surgical intervention. But when I asked intersex activists whether this warranted an exception to their position, they remained skeptical. In their view, doctors frequently plead medical necessity when performing procedures that mostly serve to perpetuate gender norms. “I find it questionable that doctors would point to fertility to justify their interventions,” Georgiann Davis told me. “Preserving fertility isn’t a concern when they remove the internal testes from other intersex people,” she added, referring to patients with androgen insensitivity syndrome, another D.S.D.

It’s hard, of course, to make general claims about all intersex cases. At the same time, it seems reasonable to draw some conclusions about Las Salinas and its unusually large population of intersex inhabitants. The town had certainly not moved beyond gender in any sort of utopian way: in fact, such norms were as rigid as you might expect in a conservative society. The menu consists of two choices: man or woman. (In discussing Johnny’s impending surgery, a tearful Claribel kept telling me, “I’m so happy because now he will be a real man.”) Yet intersex children were given time to figure out which category made sense for them. And for the most part, members of the community were satisfied to leave such decisions to the children themselves.

Where this laissez-faire acceptance came from was still something of a mystery to me. It didn’t seem to be rooted in Dominican culture. Had several generations of 5-alpha managed to transform a small town — especially one where almost everybody seemed to be related? And if so, why hadn’t the same thing happened to similar communities in Papua New Guinea and Turkey?

I wondered whether the code of respectful silence was a big part of the puzzle. I had come to Las Salinas expecting some American-style version of inclusivity: an open discussion of feelings and the correct pronouns, complemented by loud celebrations of identity. This was not the case. In Las Salinas, acceptance meant that everyone just moved on. If nobody hid the truth or lived in the shadows, nobody talked much about it either. But if the intersex inhabitants of Las Salinas attained the sort of success envisioned by doctors and activists alike — acceptance, respect, job, families — then who was I to question how they had gotten there?

Indeed, my questions, primed by the conversation about intersex in the United States, often left people confused. Nobody cared who used which bathroom at school. (When I asked, teachers and administrators looked at me quizzically and said they were much more concerned about the lack of running water.) And for his part, Johnny never tried to talk to anyone else in Las Salinas with 5-alpha. His adolescence had been laced with bullying, so I asked him what he would tell other children in his situation. He thought about it for a minute. “You need to be tranquil,” he finally said, “because you are not going to be the first or the last with this condition. You need to keep going. You need to find out what you like, what you want in life, not what your parents are telling you. What do you want?” 

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