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Nobody is arguing that babies should be raised without a gender identity, says Dr. Bruce Wilson, a pediatric endocrinologist at DeVos Children's Hospital in Grand Rapids, Mich. "Those decisions should be made reasonably quickly, within a few days," he believes. But in his view and that of a growing number of other doctors, surgery can often be postponed until closer to puberty or even later, when the child can more effectively participate in the decision and help ensure that the surgically fashioned gender fits the child's subjective sense of self.
There is a larger social issue to consider. Despite the many changes in gender roles in recent decades, our society is still fixed on the idea that there are just two separate sexes. Is the rush to early surgery a matter of medical necessity, or is it a matter of social bias that leaves doctors and parents uncomfortable with nonstandard genitalia? It's a question that more intersexuals are raising. "Doctors have found a medical solution to what is essentially a social problem," insists Thea Hillman, board member of the advocacy group Intersex Society of North America www.isna.org) "The problem has to do with differences and people's fear of differences."
Yet postponing surgery would carry its own burdens. "When children become aware of their body image at age 2 or 3 and compare their anatomy with others', questions are raised about the potential for psychological harm through their childhood," Aaronson says.
Either way, the decision to operate soon after birth isn't easy. In retrospect, Kelli's mom thinks she might have waited. "Parents can help their kids live with genitals that are different," she says. On the other hand, she acknowledges, postponing surgery might have been difficult too. "If we had left Kyle as Kyle, I'm convinced he would have felt feminine at times."
Part of what makes the decision so complex is that even when the chromosomes present a clear message on gender, anatomy may contradict it. Consider Sherri, a 45-year-old tax attorney from San Diego. Although her sex chromosomes are unambiguously XY, there is no doubt that she is a woman. Sherri has androgen-insensitivity syndrome (AIS), a condition that affects prenatal development. All embryos start out with the rudiments of male and female reproductive systems. A sort of developmental tug-of-war ensues until, generally speaking, the male reproductive system predominates in XY fetuses and the female in XX fetuses. The external male genitalia will not take shape in an XY fetus, however, until after the embryonic testes form and begin to produce testosterone.
AIS occurs when a gene on the X chromosome prevents the fetus from responding to that prenatal testosterone. Because the genitalia cannot be masculinized, they assume a more female structure. But that's not all. In the complete form of AIS, the body cannot respond to testosterone at all and the baby develops as a female, although without a functioning reproductive system. When Sherri was 11, she was told that she could never bear children because she had been born with "twisted ovaries" that had to be removed when she was a baby. In fact, the "ovaries" were her testes. "No one ever explained to me what my medical condition was," Sherri says.