Before you were ever a boy or girl you were an ‘it.’ “What is it,” was the first question new mothers asked their obstetrician upon delivery until 1956, and the advent of the obstetric ultrasound, they could see for themselves. While parents portend that a baby’s health is their primary concern, it is on average only the second question they ask at an ultrasound. In fact, your sex was and remains the first and most defining factor of your identity.

According to the National Library of Medicine, 1 in every 4,500 newborns are born with ambiguous genitalia. Thats approximately 100 intersex infants arriving in the world each day. Called androgynous, intersex is a general term used for a variety of conditions in which a newborn has chromosomal, reproductive or sexual anatomy that doesn’t fit the standard definitions of male or female, according to the Office of the United Nations High Commissioner for Human Rights.

These infants can be born with the external genitalia of one sex, while having the reproductive anatomy of the other. Or, an infant may be born with genitals that are in-between the usual male and female types. For example, a girl may be born with a noticeably large clitoris or lack a vaginal opening, while a boy may be born with a micropenis or scrotum that is divided like labia. In each and every case the infant is born with sexual anatomy that is considered ambiguous to society.

The formation of typical male or female external genitalia is a complex process involving a cascade of genetic and physiological events that begin with sex determination and progress through the differentiation of internal and external reproductive structures. When this process is disrupted, or occurs in an atypical manner, it results in a difference or disorder of sex development (DSD). 

Nature doesn’t prescribe sex. Humans do. Physicians, typically, have taken it upon themselves to decide how large a penis should be, or how small a clitoris is considered appropriate, and have proscribed anything away from the norm as intersex. Globally, long and painful reconstructive surgeries were recommended for the infant that didn’t fit neatly into one of the two socially acceptable categories leaving the child, adolescent, teenager and adult to wrestle with and reconcile that decision throughout their lifetime.

Moreover, intersex isn’t just the plight of the newborn. Nor do all DSD cases present with ambiguous genitalia at birth. More often it shows up in the teenager who fails to reach puberty; the adult seeking infertility treatment; and most commonly in the postmortem, where an autopsy reveals the characteristics of two sexes. Indeed, many people live and die with intersex anatomy without ever knowing it.

The transgender rights movement may be the new frontier and next battle for civil rights, but they are not the 100 or so intersex newcomers who present themselves in our world each day. A transgender person is someone whose conscious ideas and identity about their gender differ from the sex they were assigned at birth. An intersex person is a physical, scientific and biological expression of someone society doesn’t quite recognize.

The first transgender character ever portrayed on television, Asia Kate Dillon of Netflix “Billions” explains that difference thus: “Sex is between your legs. Gender is between your ears.” Its critical we keep science and civil rights in their proper spheres.

Today, a multi-disciplinary team specializing in DSD in accordance with international recommendations on diagnostic and therapeutic strategies greets the intersex newborn. They provide holistic care and treatment guidance, collaborate closely with relevant sub-specialists and peer support groups that includes: psychology, pediatric endocrinology, urology, neonatology, gynecology, nursing, social work, genetics, and most importantly medical ethics. Still, DSD management remains contentious or uncertain, resulting in recent changes in clinical practice that are ongoing.

While feminizing and masculinization surgeries were recommended and performed on infants with intersex anatomy through the 20th century, Malta was the first country to ban unnecessary surgeries on children with sex variations in 2015. Since then, Germany, Greece, Iceland, Portugal and Spain have followed suit. Austria, Cyprus and France have tabled proposals for bans. And in the United States, legislators across the country have introduced, piggy-backed and passed bans that limit access to gender-affirming medical care for transgender youth. Sadly, those same bills have explicitly allowed an exception for surgery on intersex minors.

In New York State, parents can now proudly mark the letter (X) on their newborn’s birth certificate. Nearly half of the 50 states can now choose the letter (X) on their drivers license. And all U.S. citizens can select male (M), female (F), or an unspecified and alternate identity (X) as the gender marker on their U.S. passport book and card. The gender they select does not need to match the gender on their birth certificate, drivers license or photo ID. Nor do they need to provide medical documentation to change their gender marker.

While the intersex newborn is a manifestation of natural science, society is presented with an opportunity for renewal: to debunk the myth that merely two genders exist when a kaleidoscope of variations present themselves each and every day. Perhaps, someday, we’ll stop asking “what is it,” but rather accept, embrace, and celebrate “who it is ...”