Pseudohermaphroditism

Pseudohermaphroditism (also spelled pseudo-hermaphroditism) is an old clinical term for an organism that is born with primary sex characteristics of one sex but develops the secondary sex characteristics that are different from what would be expected on the basis of the gonadal tissue (ovary or testis). It can be contrasted with the term true hermaphroditism, which described a condition where testicular and ovarian tissue were present in the same individual. This language has fallen out of favor due to misconceptions and pejorative connotations associated with the terms, and also a shift to nomenclature based on genetics.

The term male pseudohermaphrodite was used when a testis is present, and the term female pseudohermaphrodite was used when an ovary is present.

In some cases, external sex organs associated with pseudohermaphroditism look intermediate between a typical clitoris and penis. In other cases, the external sex organs have an appearance that would be expected to be seen with the "opposite" gonadal tissue. Because of this, pseudohermaphroditism is sometimes not identified until puberty or adulthood.

Associated conditions include 5-α-reductase deficiency and androgen insensitivity syndrome.

Genetics

Sex determination and differentiation is generalized with chromosomal sex during fertilization. At early stages, phenotypic sex does not match chromosomal sex. This occurs only later during intrauterine development when sexual maturation is reached. During intrauterine development, females change to male, as the testes move down from a blind vaginal pouch with a developing scrotum, and a penis develops from what initially resembled a clitoris. What seems like a female phenotype is altered by increased testosterone secretion.

Mutations affecting the androgen receptor (AR) gene may cause either complete or partial androgen insensitivity syndrome. Androgens (a term used to describe a group of sex steroid hormones) are responsible for male pseudohermaphroditism. The differentiation of the fetus as male takes place during the sixth or seventh week of gestation. The development is directed by the sex-determining region on the Y chromosome (SRY). Throughout the 9th to 13th week, the development of male genitalia is dependent upon the conversion of testosterone to the more potent androgen dihydrotestosterone by the action of 5α-reductase within the target tissues of the genitalia.

A type of internal male pseudohermaphroditism is Persistent Müllerian duct syndrome, which is developed through synthesis of Müllerian-inhibiting factor defects. In such instances, duct derivatives are now in 46XY males—this includes the uterus, fallopian tubes, and upper vagina. These individuals with a hernia sac and bowel loops were found with duct derivatives as well as testes.

A study of a male pseudohermaphrodite kitten showed that there was a combination of gastrointestinal and urogenital congenital abnormalities. It was confirmed to have type II atresia ani and rectovaginal fistula, which is associated with male pseudohermaphroditism.

Management

Surgery is sometimes performed to alter the appearance of the genitals. However many surgeries performed on intersex people lack clear evidence of necessity, can be considered as mutilating, and are widely considered to be human rights violations when performed without the informed consent of the recipient.

History

John Money is perhaps the best-known early researcher in this area. His doctoral thesis was titled Hermaphroditism: An Inquiry into the Nature of a Human Paradox, and awarded by Harvard University in 1952.

Money's general views on gender identity as something learned during childhood were later directly contradicted by a biography published in 2001 by one of his former patients, David Reimer. Among the repercussions was damage to John Money's reputation. Not only had his theory of gender plasticity been dealt a severe blow but Reimer's biography described bizarrely unpleasant childhood therapy sessions, and implied that Money had ignored or concealed the developing evidence that Reimer's reassignment to female was not going well. Money's defenders have suggested that some of the allegations about the therapy sessions may have been the result of False memory syndrome. However, Reimer's brother and mother both agreed that the therapy was not "working" in the sense that Reimer wasn't in any way developing a female self-image during his treatment with Dr. Money. Dr. Money never publicly stated that his conclusions were incorrect.

Milton Diamond become a well known expert public advocate on intersex in the early 21st century. He is the director of the Pacific Center for Sex and Society.

Terminology

Use of the term "pseudohermaphroditism" can be problematic, and is now considered redundant. The term "pseudohermaphroditism" was created by Edwin Klebs in 1876, long before the genetic roles of the X chromosome and Y chromosome and the social components of gender identity were well characterized, which is why the term is usually used to describe the dissonance between gonadal histology and external genital appearance.

The term "intersexuality" was introduced by Richard Goldschmidt in 1923. However, the term "intersex" has also been challenged; the Lawson Wilkins Pediatric Endocrine Society and the European Society for Pediatric Endocrinology have adopted a nomenclature system based on disorders of sex development (DSD), which covers "congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical" and thus replaces many disparate terms, including but not limited to those based on "hermaphrodite".

While it adopted the term to open "many more doors", the now defunct Intersex Society of North America itself remarked that intersex is not a disorder. 'DSD' is itself heavily contested, including by civil society organizations, human rights institutions and academics. Academics like Georgiann Davis and Morgan Holmes, and clinical psychologists like Tiger Devore, argue that the term DSD was designed to "reinstitutionalise" medical authority over intersex bodies, making intersex bodies more treatable and more of a stigma (Holmes), or to place intersex "neatly into medical turf and safely away from critics of its medicalisation" (Davis). In May 2016, Interact Advocates for Intersex Youth published a statement opposing pathologizing language to describe people born with intersex traits, recognizing "increasing general understanding and acceptance of the term "intersex"".

One example of the challenges involved in the use of the term is the case of women with complete androgen insensitivity syndrome (CAIS). These women often have primary and secondary sexual characteristics typical of other women; however, they are karyotypically XY and have internal testes, rather than ovaries. They have the same likelihood as a karyotypically XX woman of enjoying sexual pleasure but are unable to biologically reproduce. Their sexuality (homosexual, heterosexual, bisexual etc.) is not necessarily determined by this syndrome. However scientifically precise the description "male" pseudohermaphrodite may be for such women, its social inappropriateness is in controversy.

See also

• (DoDI) 6130.03, 2018, section 5, 13f and 14m
• Disorders of sex development
• Intersex medical interventions
• Intersex human rights