People often believe that everyone is born distinctly male or female. However, nature reveals a different reality. Approximately 1 in 2,000 infants is born with genitalia that is neither clearly male nor female, often presenting characteristics of both. More subtle forms of ambiguous sex development are surprisingly common, with estimates suggesting that as many as 1 in 100 individuals may possess some variation that diverges from traditional male or female classifications, though many may never become aware of it.

Despite this, societal norms strongly favor a binary understanding of gender. Many medical professionals argue that while societal constructs can't be altered, they must take steps to perform 'corrective' surgeries on intersex children to align their appearances with cultural expectations of male or female bodies. In the U.S., it is estimated that at least 1 in 300 children is born with a noticeable difference in sex development, prompting recommendations for specialist consultations.

Conditions such as hypospadias, where the urinary opening is located lower on the penis than usual, are more frequently observed in boys. Girls, too, can have atypical sex development, with conditions leading to an enlarged clitoris that may resemble a small penis.

These variations are simply part of a developmental spectrum. The clitoris and penis originate from the same embryonic tissue, just as the labia majora and scrotum do. Most newborns will develop genitalia that clearly fall into either the male or female category, but not all do.

Moreover, sex biology encompasses much more than just external genitalia. It is influenced by a variety of factors, including hormones and reproductive organs, leading to numerous forms of intersex development. Some intersex conditions remain undetectable at birth; children may appear typically male or female but possess internal organs of the opposite sex. Others may discover their intersex traits during puberty or later in life when facing fertility challenges.

Being diagnosed later in life allows individuals the opportunity to make informed choices regarding their bodies. Conversely, babies born with genital differences often have decisions made for them. Since the 1960s, it has been standard practice in pediatric medicine to surgically alter visible intersex characteristics to conform to societal norms.

Hypospadias repair surgery, which relocates the urinary opening to the tip of the penis, is a routine procedure that many pediatric urologists refer to as a 'bread and butter' operation. These surgeries are performed not only to address aesthetic concerns but also due to the belief that normal male functioning requires the ability to urinate standing up.

The controversy surrounding such surgeries has intensified over the last two decades, with intersex rights activists framing them as human rights violations. They argue that children should be given the autonomy to decide for themselves about undergoing any surgeries that alter their sex characteristics.

While genital surgeries may be common, they are not without risks. A prominent pediatric urologist acknowledged in 2015 that the complications faced by patients post-surgery have often been underestimated. More invasive procedures, such as the removal of testes in genetically male children, can permanently alter sexual sensation and eliminate the possibility of reproduction.

Historically, the medical community has often prioritized surgical changes to make intersex children appear female, based on the belief that constructing female genitalia is easier than creating male genitalia. Over time, the outcomes of these surgeries have been assessed primarily through the lens of whether the individuals later conform to societal expectations of heterosexual marriage.

While most agree that lifesaving surgeries are necessary, many early childhood intersex surgeries are not medically required. They are performed instead due to a desire to conform to cultural norms surrounding gender.

These surgeries can lead to increased physical risks, and many individuals later regret having undergone elective procedures. Most intersex advocates do not oppose their gender assignments but object to the removal or alteration of their body parts without their consent. The United Nations Committee Against Torture is now investigating these surgeries, propelled by activists who describe them as a form of "intersex genital mutilation."

The Committee has already reprimanded several countries for their practices and has requested details from Australia and the U.S. regarding the prevalence of these surgeries. The U.S., as a signatory of the Convention Against Torture, faces scrutiny over its adherence to these human rights standards.

Despite widespread condemnation of practices like female genital mutilation (FGM), surgeries on intersex children remain common and often viewed as necessary. Current anti-FGM laws may parallel what occurs during some intersex surgeries, yet many legal protections for intersex children are not enforced.

An international consortium of pediatric urologists has recently rejected the UN's framing of intersex surgeries as human rights abuses, arguing that these procedures are essential for meeting parental expectations and ensuring future sexual function.

However, this perspective relies on problematic assumptions about predicting a child's gender identity. There are numerous instances where medical professionals have misjudged a child's long-term gender identification. Removing or altering genital tissue based on these assumptions raises ethical concerns, particularly as some individuals later identify as a gender different from that assigned at birth.

Even individuals who grow comfortable with their gender assignments may not have desired unnecessary removal of their sexual tissues. The belief that typical appearance and function are prerequisites for satisfactory sexual experience is not universally true.

Historical evidence suggests that many intersex individuals have enjoyed fulfilling sexual lives without surgical alterations. Despite the medical community's tendency to dismiss former patients' dissatisfaction as a result of outdated techniques, the reality remains that any surgery carries inherent risks, particularly with delicate genital tissues.

Throughout the ongoing discourse about intersex rights, countless individuals have expressed anger about their childhood surgeries, while not a single person has publicly stated satisfaction with having undergone elective procedures. This raises significant questions about the motivations behind such surgeries.

Medicalization of benign variations in sex development often subjects intersex children to invasive examinations, which many describe as traumatic experiences. Intersex individuals frequently express a desire for an end to medical scrutiny of their bodies and to simply be accepted as they are.

Historically, children with intersex traits were successfully raised as boys or girls without surgical intervention. The idea that gender identity cannot be assigned without conforming to specific physical characteristics is a misconception that has evolved only recently.

As society progresses in recognizing the rights of children and youth, including protections against FGM and sexual assault, it is imperative that intersex rights receive equal attention. The tension between viewing intersex variations as human rights concerns versus medical issues requiring correction is escalating.

Medical professionals involved in these practices are not inherently malicious; rather, they aim to prevent stigma. However, stigma should be addressed through social and psychological means. A more cautious medical approach would align with the principle of "first, do no harm."

Instead of expecting intersex children to conform to societal norms, a shift in parental attitudes toward acceptance and understanding is necessary. Just as society has redefined parental rights concerning child labor and abuse, a similar evolution can occur regarding intersex children, prioritizing their wellbeing and acceptance of natural variations in sex development.

It is crucial for pediatricians to recognize intersex issues as human rights matters and guide parents in fostering acceptance and understanding.

Alice Dreger is a historian of medicine and a science writer whose work has appeared in The New York Times, The Atlantic, and The Wall Street Journal, among others. Her latest book is Galileo’s Middle Finger: Heretics, Activists, and the Search for Justice in Science (2015). She resides in Michigan.

Edited by Sam Haselby.