Everyone gets caught in the middle of things from time to time. Being stuck in the middle often forces people to make choices. Granted, not all decisions have a significant and life-altering impact, most can only imagine being forced to make a choice during early childhood years that will dictate the course of their entire life. Most cannot begin to understand how it would feel to have that choice made for them. One can only dream of what it would be to have destiny in his or her own youthful hands, or to have it stolen from them. He or she can only wonder what it would be like to be the middle child, but there are children who know this as a harsh reality. What most cannot begin to comprehend, hermaphrodites experience daily. They are the middle children of the world.

In many societies, intersexuals feel the need to shroud their lives in secrecy out of disgrace and humiliation. Most intersex children live day by day in a world of constant confusion. Among various societies, intersexism, an age-old condition, is viewed as bringing about either a deformed sex in need of repetitive corrective surgeries or merely a call for recognition outside the limits of today�s male and female identities. Not surprisingly, many people do not know what hermaphroditism, or the more appropriate term, intersex or intersexuality, is. Though intersex can be traced as far back in time as the biblical ages, only recently have scientists been able to unlock the doors leading to the many rooms bursting with the secrets of sex and gender. Simple sex chromosome irregularities are present in one in every three hundred to four hundred births (as often as Down syndrome). Many variations do not result in ambiguous genetalia (Miller 2). Intersex surfaces in one in every two thousand births, making it as common as cystic fibrosis. According to historians, Joan of Arc, Queen Elizabeth I and Wallis Simpson may have been intersexuals (Driedger 1). Evidence of hermaphrodites and ambiguous genetalia has been found in ancient cultures. According to Anne Fausto-Sterling, a professor at Brown University, statues of intersexuals still exist in Rome (Alvarado 4). Despite its long-standing history, many people remain unaware of this condition.

One must wonder how something so age-old and unique could remain so secretive. So little is known about intersexuality due to the fact that until recently it has been viewed as unmentionable and taboo. Parents have often been warned to keep the condition a secret from their affected children (Driedger 1). Fortunately, compassionate doctors, therapists, and sociologists have begun to make discoveries which provide information aiding in lifting some of the shame associated with the term �hermaphrodite.� Thanks to extended research and gained knowledge, intersex is gradually becoming more and more public. However, prejudices exist within T.V. shows such as ER and Friends which have insensitively portrayed intersex as shameful and pitiful. On the other hand, books such as Normal, a collection of essays by Amy Bloom, and also Middlesex, a novel by Jeffrey Eugenide, have provided a more sensitive approach to the subject (Driedger 2). Works such as these have opened eyes and turned heads toward the almost limitless boundaries of intersex.

Similar to any commonly known birth defect or condition, intersex appears in various forms. Of the separate diagnoses of intersex, most types have one or more suspected causes. Many of these occur due to abnormalities within the first nine weeks of the gestational period. In examining any form of hermaphroditism, one must understand that karyotype is defined by the amount of XX- versus XY-chromosomes. Average female karyotypes have 46,XX chromosomes, while males have 46,XY chromosomes (Wheeler �Hermaphrodites� 307). In many cases, karyotypes aren�t enough when it comes to determining the sex of a fetus. The presence of a Y-chromosome determines whether ever-present male genitals develop rather than remain in an underdeveloped form within the body. The Y-chromosome also determines levels of testosterone, types of genitals (penis or clitoris), gonads (testes or ovaries), type of reproductive sex (egg or sperm), and �associated� internal organs (uterus and prostate) (Nataf 3). For the first nine gestational weeks, males and females possess the same gender-neutral external genetalia including a phallus and labioscrotal folds. Phalluses become either a penis or a clitoris while labioscrotal folds take form of either the scrotum or labial folds. Results depend on amounts of testosterone released (Wheeler �Pseudohermaphroditism� 474). Essentially, it is the Y-chromosome which directs male development. Everything, including genetics, has its flaws. Sometimes, sex is incomplete, and others, it may even be considered overly complete. One in every two thousand children possesses ambiguous genetalia, often including the following: Ambiguous genetalia typically consist of a small, abnormally shaped, phallus-like structure, often with hypospadias (in which urine comes from the base of the penis instead of the tip) and abnormal development of the labioscrotal folds (not clearly a scrotum or labia). A vaginal opening may be present. (Wheeler �Pseudohermaphroditism� 474) Physical characteristics of hermaphrodites range from complete male external genetalia with female gonads to total female genetalia accompanied by male gonads. Most intersexuals lie somewhere in between these two extremes. Gonadal structure brings variations of its own. An ovotestis (one gonad with both male testicular and female ovarian tissues) may be present. An ovary and a testis may appear on opposite, same or even both sides (Wheeler �Hermaphrodites� 307). �Intersex� is a broad term used in labeling any individual born with ambiguous genetalia. There are many forms of intersex as well as variations within each of these. Type I Intersexuality or female pseudo hermaphroditism is often caused by increased levels of testosterone during the first half of pregnancy. Such levels of testosterone may be caused by the use of anabolic steroids by the mother during pregnancy. One form of Type I, Congenital Adrenal Hyperplasia (CAH), is caused by abnormal enzymes in development of the fetus. CAH causes increased testosterone and decreased cortisol (a stress hormone) levels and is characterized by virilization (masculinization) of female genitals (Miller 2). Turner�s syndrome results from a single X-chromosome. Seventy-five percent of victims die in utero. Without treatment, victims develop mostly female characteristics but are infertile and often incapable of female genital or gonadal maturation. With treatment, victims can live and develop as females (Miller 2). Opposed to female pseudo hermaphroditism, male pseudo hermaphroditism or Type II Intersexuality has more than two variations. Type II is caused by an infant with male chromosomes not receiving testosterone due to either a lack of the enzyme which produces testosterone or broken receptors of the enzyme. Some male pseudo hermaphrodites begin producing the necessary levels of testosterone in puberty and may transform into �normal-appearing� males (Wheeler �Pseudohermaphroditism� 474). Two other variations of male pseudo hermaphroditism exist. Testicular Feminization Syndrome or Androgen Insensitivity Syndrome (AIS) is caused by missing androgen (hormone that promotes male body characteristics) receptors from within male cells. The lack of androgen leads to development of female genetalia despite the 46,XY karyotype. This condition surfaces in one in every twenty thousand births (Miller 3). Another form, Klinefelter�s Syndrome is the result of an extra X-chromosome, causing XXY-chromosomes along with male gonads and underdeveloped male genetalia including un-descended testes (Miller 2). Pseudo hermaphrodites are said to be the outskirts of intersexuality. The rarest form of intersex is known as the �true hermaphrodite.�

Among �true hermaphrodites� or Type III Intersexuals, fifty-eight percent of have 46,XX (female) chromosomes and could be expected to develop into an average female fetus. Likewise, twelve percent have 46,XY (male) chromosomes and, therefore, could be expected to develop into an average male fetus. There are separate terms for intersexuals within the limits of �true hermaphroditism.� Variations among Type III Intersexuality include mosaicism and chimerism. Mosaicism occurs if a chromosome is lost or gained in early development drastically altering the karyotype. In contrast, chimerism is caused by two completely different cell lines merging together creating a double karyotype which is written 46,XX/46,XY. Fourteen percent of hermaphrodites are chimeras. Scientists suspect chromosome abnormalities leading to Type III lay hidden deep within the gonadal tissue (Wheeler �Hermaphrodites� 307-308). With extended history, numerous theories, and various forms of intersex, many controversies exist.

Mention of intersex results in many discrepancies. Arguments flare when discussing what sex and gender are. Sex and gender are two separate terms, which are often mistakenly interchanged. Today sex is accepted as referring to whether a person is male or female based on biology. Gender is defined by the mental, social and traditional aspects associated with a person as being girl or boy (Nataf 3). Traditionally, gender is designated at birth depending on sex. According to doctors, clitorises should be no longer than nine-tenths centimeters and penises no shorter than 2.5 centimeters. Corrective surgeries are both painful and scarring and often unnecessary (Nataf 2). When doctors �correct� ambiguous genetalia, they are correcting a predicted gender of a child rather than its actual sex. This fact lays foundation for arguments regarding gender itself.

Psychiatrists disagree on whether gender is ascribed or assigned at birth. According to Dr. John Money, a Hopkins psychologist, gender identity is not present at birth, and children are in a �blank state� (Miller 3). On the contrary, Hopkins Psychiatrist William Reiner claims the following: �The sense of who one is � boy or girl � is a crucial existential aspect of humanity. It is powerful and inborn [�] the most important sex organ is the brain.� Reiner deducted this when he confessed to an unhappy and aggressive seven-year-old girl that she was born as a boy without a penis. Upon hearing this, the child would not move from the doctor�s arms for over half an hour (Hendricks 1). This controversy influences how society as a whole views intersexuals.

Cheryl Chase, the founder of the Intersex Society of North America and a �true hermaphrodite,� claims, ��In the second half of the twentieth century, doctors have treated intersex as something that is so freakish that it renders the intersex person ineligible for membership in society�� (Matthews 1). Intersexuals are viewed as �freaks� or �monstrosities� and are �corrected� against their will as infants (Miller 3). According to Zachary Nataf, transgender activist, doctors view ambiguous genetalia as �deformed and later �corrected� as opposed to most intersexuals who recall being �in tact� and later �mutilated�. Nataf also suggests, �In most parts of the world [�] sexually ambiguous bodies are threatening. Perhaps, they elicit desire, possessing it might seem an erotic potential beyond those with ordinary genitals. Maybe the notion of sex or gender mutability provokes a kind of terror or gender vertigo� (2-3). It has always been human nature to correct that which is broken. However, it is unclear as to who can rightfully define what is broken or not and what should be done about it.

In societies that rely on surgery as the only option in dealing with intersexism, arguments rage about which practice is ethical or in many cases convenient. Many doctors feel that surgery is absolutely necessary. A pediatric urologist at the Medical University of South Carolina and chairman of the North American Task Force on Intersex by the name of Dr. Ian Aaronson insists, ��Most doctors would feel uncomfortable leaving children with grossly ambiguous genitalia, to grow up through school with something strange between their legs�� (Matthews 1). Over 2000 sexual reassignment surgeries are performed every year in the U.S. on intersexuals (Nataf 2). In some cases, surgery is necessary. For example, if the gonads of the undesired sex are not removed, risks of cancer increase in 46,XY karyotypes (Wheeler �Hermaphrodites� 308). CAH is life-threatening (due to low cortisol levels) if left untreated (Wheeler �Pseudohermaphroditism� 475). Unless it is necessary, many authorities are opposed to early (or any) surgeries.

Many doctors, intersexuals and therapists are opposed to surgery. Nataf presses that �the adage that �it is easier to dig a hole than build a pole� accounts for why most intersex individuals [have been] made into girls.� Surgery is performed before long-term problems are notable, as early as six weeks (2-3). Aurthur Frank, a University of Calgary sociology professor and member of the Surgically Shaping Children project group at the Hastings Center, notes, �Parents often want what�s best for their children, and best often translates into normal� (Driedger 3). Danette Ivey, born with CAH, had nine surgeries between the ages of three months and seventeen years old. According to Ivey, You feel totally violated [�] you lose all control of your body because you have your parents and the doctors saying, �We�re doing this to make you normal.� In my mind, I was normal until they started cutting on me. (Matthews 1) Ivey�s message to parents is as follows: ��Don�t do anything that is not medically necessary. Let the child decide when they are older, because once you do the surgery, you can�t go back�� (Matthews 1). Surgeries often cause more harm than good in patients. They are often misguided and leave victims sexually unresponsive (Miller 3). As knowledge continues to grow, controversies will eventually begin to subside, allowing for greater overall acceptance.

Every choice has a consequence, every cause an effect, every action a reaction. People are becoming more open-minded in approaching the limits of gender as definitions of male and female are being drastically altered. Dr. Daniel Metzger, a pediatric endocrinologist at British Columbia�s Children�s Hospital in Vancouver cautions, that the biologically perfect male or female may only be an illusion [�] Metzger contends that sexuality is a continuum, with many people falling somewhere in between the poles of �pure� male and �pure� female � and with intersexuals in the middle. (Driedger 2) Even the ability to reproduce doesn�t define what is essentially male or female. Some intersexuals have children of their own (Nataf 3). Due to this reasoning, professionals are acknowledging the possibility of multiple genders. Dr. Anne Fausto-Sterling, a developmental geneticist and professor of medical science at Brown University believes the following five sexes exist: �males, merms (Type II), herms (Type III), ferms (Type I), and females� (Miller 3). This means little to intersexuals who may have already been �mutilated.�

After years of hiding in their own bodies, Intersexuals are beginning to speak out. The main goal of the Intersex Society of North America, founded by Cheryl Chase, is to ��end shame, secrecy and unwanted surgeries for people born with atypical sex anatomy�� (Miller 3). The ISNA views gender surgeries on infants as unethical because the patients cannot give consent. Ms. Chase argues that �most people would be better off with no surgery.� Repetitive surgeries and examinations often sacrifice orgasmic response (Nataf 2). Many intersexuals are unable to compensate for what has been decided for them, but they continue to explore future options.

Intersex persons are delving into opportunities relating to surgery (or no surgery) with regard to earlier procedures. Many intersexuals choose not to have surgery and boldly cross the gender line. They claim, �It�s simple. Some men don�t have penises and have vaginas; some women have penises and don�t have vaginas� (Nataf 4). Singer Eden Atwood appeared to be an attractive, �normal� young woman. She didn�t realize her intersex identity until her semi-drunk step mom blurted out that she didn�t menstruate because she�s �half-man, half-woman.� Long after her initial shock and disappointment, she has revealed her secret. She has developed a whole new attitude and encourages others like herself to feel no shame (Driedger 2). Others opt to have surgery. Some intersex people are undergoing surgery in order to either restore hermaphroditic, bi-gendered bodies in order to match their �core sense of who they are� (Nataf 4). With these surgeries, attention is called to attitudes of those who have undergone involuntary operations. Many societies are examining and altering methods of �normalizing� appearances of ambiguous genitalia. Doctors perform follow-ups on those treated at early ages. Throughout two experiments involving a total of thirty-six individuals with male chromosomes but a lack of male genetalia, two of whom have been raised as boys and thirty-four as girls, subjects were observed by William Reiner for eight hours. After observation, clinical depression was diagnosed in eight girls along with two confessed past suicide attempts. None of the girls were dating, and all had masculine personalities. After observation, twenty-two of the patients raised as girls decided to undergo reassignment surgery. Both individuals who were raised as boys demonstrated no psychological difficulties (Hendricks 2-3). As of recent observations similar to Reiner�s experiment, surgery decisions are evolving into chromosome-based conclusions (Wheeler �Pseudohermaphroditism� 475). Surgeons are finally agreeing that perhaps intersexuals should be able to determine their own sex (Driedger 3). It�s not only professionals and experts who are beginning to alter their beliefs on surgery.

Parents are beginning to allow affected children to mature and make their own choices regarding their gender. The story of the Hartman baby is a prime example. Ruth Padawer tells the story which begin as follows: ��Mrs. Hartman,� the doctor at her bedside says, �your baby�s fine, but we don�t know whether it is a boy or a girl.�� According to doctors, �Baby Hartman� is predominantly male, and surgery was necessary to clear up �anatomical confusion.� The Hartmans name their baby Kyle, but ten weeks later, during an operation, doctors claim to have found �streaks of testicular and ovarian tissue� and that Kyle would be �better off as a girl.� Deb Hartman cries, ��How can you tell me he�s a girl when you just convinced me he was a boy? How am I supposed to see that same little face and think of him as a girl?�� The Hartmans were to raise Kelli Rene as a girl and not reveal her secret. Deb recalls, ��It was like having twins; as if my twins went into surgery and Kelli made it and Kyle didn�t. I was so thankful Kelli was there, but I mourned the loss of my son.�� By age four, Kelli begins to insist that she�s a boy and that she�s �tricking everyone.� By third grade, Kelli throws tantrums if Deb refers to her as a girl when talking about her, yet she�s equally angered when she�s mistaken for a boy. By the time her daughter starts referring to herself as Max, Deb begins to blame herself for possibly allowing surgeons to make a grave mistake. At age eight, Kelli accuses her mother of keeping a horrible secret from her. She knows that something is amiss. Deb finally decides to let Kelli take matters into her own ten-year-old hands, but Deb can�t help but wonder, ��How do you explain gender and sexuality to a kid who�s only ten? How do you know when she�s ready to make a decision that will affect her the rest of her life�� (Padawer 2)? A couple in Ontario, under similar circumstances, have also decided to allow their child to mature.

An anonymous Ontario couple gives birth to an infant who has testes and male chromosomes along with a uterus, an ovary, and a fallopian tube. The child undergoes feminization surgery and her testes are removed. However, the parents cease consent for future surgeries after realizing the public�s reaction as, the previously mentioned jazz singer, Eden Atwood, proudly declares, ��No one said a damn thing,�� regarding her confession and her attitude toward life in �the middle ground� (Driedger 1-3). Thanks to growing public awareness brought by the popular blues singer, much discrimination has been cast away.

Intersex has a lengthy history filled with medical, ethical, and personal controversies, many of which are beginning to subside thanks to the �coming-out� of media figures, the brilliant follow-up experiments of professionals, the persistence of outspoken intersexuals, and the concern of loving parents. More knowledge is being attained as taboos are being lifted away from hermaphroditism. Hopefully, in the future, these individuals will finally be able to live and mature in peace, a peace which depends and reflects on their own morals and resolutions.

All things considered, the question remains: does the ancient condition, intersex, call for immediate corrective surgery, or does it simply demand that society recognize another gender, if not multiple genders, outside the male and female identities? Even if a person cannot control or alter the past, they can always choose the way in which they�ll react. Hermaphrodites don�t choose to be born with ambiguous genetalia. They don�t ask doctors to mutilate that which they may have held dear. They can, however, decide what they want their destiny to be. That is exactly what they�re doing, whether it is through voluntary surgery or objection to it. They are making themselves heard, and the more they continue to do so, the better their chances are for achieving a greater acceptance as the middle child.