Intersex, DSDs, and Sex as a Spectrum

Jimmy Knibbe
13 min readApr 1, 2021

There has been much confusion and debate surrounding the question of sex in humans over recent years, as many people advocate for sex as a spectrum, as opposed to a binary. The common argument used in the sex-as-a-spectrum position is that the existence of ‘intersex’ people shows that sex is not as binary as we think.

For most people, this is a simple debate over definitions; but for me, it’s a lot more personal. My daughter falls in the ‘intersex’ category and, as such, she is being used in a way that is dishonest, damaging, and dehumanizing. More on that later.

In the process of wrestling with the Intersex and Sex-as-a-Spectrum view, I’ve discovered that it’s difficult to find out information regarding the types, frequency and severity of these conditions. This page is meant to be an informative resource for any who are interested in learning more.

If you are interested in the types and frequencies of all Intersex conditions, then please use this link to see a summary: https://docs.google.com/spreadsheets/d/1-TnFYGpbWsYul7sXQ5uS7vylG-NRKC7mP-_eV4JucCE/edit?usp=sharing

The list is not exhaustive, but it does contain sources, and includes over 30 conditions, with their frequencies and whether or not they cause any kind of ambiguity or uncertainty of sex.

If you want to understand what ‘intersex’ really means, and a better way to frame the conversation, and if we should think of sex as a spectrum, then please read on. I have tried to make this informative and well-researched, while also keeping it accessible to laymen like myself. If you have any corrections, please send me a note on twitter — @CanuckPlucky — or leave a comment!

First things: Sex Development, Intersex, DSDs, and the In-Between

Firstly, the term ‘intersex’ is a political one, and a lot of the confusion and disagreement is over misunderstanding of terms (ain’t it always?). For that reason, we need to clarify some things.

The fundamental confusion is that the development of sex within individuals is a process, and there are many places along that process where things can go awry. Think of the process for building something: there can be a mistake in the original instructions, or the wrong blueprints get used, or the head foreman gives the wrong direction, or the workers don’t listen to the foreman.

Sex Development: Analogous to Construction

Any mistake in this system might result in the building not operating as intended; a significant mistake (different blueprints being delivered) might result in a car factory being built, instead of a factory to produce golf balls. However, it’s possible that a mistake in this system will also have no meaningful impact, like if an extra copy of the correct blueprints gets sent to the foreman, or if a worker only ignores the foreman when he installs an air vent incorrectly. A car factory with a broken air vent is, after all, still a car factory.

Disorders of Sex Development (DSDs) capture any breakdown or mistake in the process related to sex development, but as a category does not differentiate between the proverbial broken air vent and the construction of a completely different factory. As a result, this makes it a very broad term and, yes, includes perhaps 2% of the population, as Ann Fausto-Sterling’s infamously claimed. Over half of this have the (by far) most common DSD, the mild form of Congenital Adrenal Hyperplasia (CAH), which can cause some mild irregularities, like above-average body hair growth and irregular menstrual cycles in adolescent females.

For all intents and purposes, people with mild CAH are like the factory building with a broken air vent. It may cause some minor problems but does not generally impact the overall function and purpose of the structure. Females with CAH are, quite clearly and obviously, female. Males with CAH are, quite clearly and obviously, male. The only way to deny this would be to argue that having an irregular period, or a little extra arm hair, equates to an individual not being a female. Is anyone out there seriously contending that?

So we can clearly state that people with DSDs (often called ‘intersex’) do not, as a group, always illustrate that there are individuals who are ‘in between’ male and female. Many of them are unequivocally male or female, in spite of their disorder. At the same time, there are individuals within that 2% of the population for whom sex assignation is not so clear.

When people use the term ‘intersex’ in the context of the sex-as-a-spectrum argument, what they are really referring to is the group of people whose sex is ‘in-between’ male and female. What they really mean is that sex, for these people, is ambiguous, or unclear, or not easily categorized. They are referring, to use my analogy, to buildings which are not clearly identifiable as car factories or golf-ball factories, but which seem to share fundamental qualities of both.

For clarity, I will be using the term sex-ambiguous to describe these individuals. These individuals are really at the heart of the issue, and this term does not lump all people with DSDs into the mix, and avoids the political and mostly subjective ‘intersex’ term. So, do sex-ambiguous people exist? How common is sex ambiguity in humans?

Well, that depends on how you define sex.

Let’s talk about sex, baby.

Many people think of the following process and get confused over where and how we should define sex. Is it the genes we have (ie: do I carry the SRY gene?)? Is it the chromosomes (XX or XY)? Is it how much testosterone my body produces (after all, this drives sex development)? Or is it my physiology (ie: what genitalia I have)?

This problem has led many to conclude that there are just too many variables, and too many ranges, so therefore there is no accurate system to differentiate sex. However, all of this is a misunderstanding of what sex is. From a biological standpoint, we don’t define sex by individuals or the variations within the species — we define sex by the number and variety of gametes that a species produces.

A gamete is the reproductive cell of a species. Our bodies are, for all evolutionary intents and purposes, mechanisms designed solely to bring those types of cells together in an ever-repeating cycle of reproduction. And as our species is diploid, that means we have two different types of gametes: sperm and ova (egg). That’s it: two types. And our bodies are organized around the production of one or the other of these gametes.

To clear up a common misconception: there has never been an individual who has been able to viably produce both sets of gametes (hermaphrodite); this does not occur in humans. Ever. But there are individuals for whom it can be difficult to determine which gamete their body is organized to produce.

despite this, this is the way we must define sex: by the gamete type that a bodies is organized to produce. This is the fundamental quality of our sex, as gametes are the fundamental priority of reproduction. It is the definition which produces the best clarity of meaning (ie: provides the most accurate categories) as it dispenses with all the trivial qualities which may, or may not, occur.

If a factory is organized around the production of cars, then its function is not changed if an air vent works or not. It is irrelevant if the factory has workers in it or not, or all the different machinery, or produces cars regularly or sporadically. It is irrelevant if the blueprints for that factory included extra copies or if the architect made a random mistake or if the foreman gave a few wrong instructions; its design clearly indicates that it was built to produce cars. If we focus on any one of the myriad little details then of course we can argue that there is no perfect line between factory made to produce cars and one made to produce golf galls; strip away enough ‘optional’ individual qualities and every major category becomes indistinguishable. But the individual who takes this approach is really saying that any classification and any categorization is impossible because we cannot differentiate perfectly between all cases and all structures.

That way lies madness. The reality we must accept, in order to have any meaningful dialogue at all, is that a building mainly organized around building cars is a car factory. And a building mainly organized around making golf balls is a golf-ball factory. To define anything by its minor individual qualities is to invite disaster and confusion. A car, a chair, a phone book… all these categories only exist with any coherent meaning if we accept that the fundamental purpose and organization of the object is consistent, despite the many variations from one individual example to the next.

If you want categorization to be perfect and without error or ambiguity, then you may as well cease to speak and think. If you want to break apart all categories into a spectrum of all traits and qualities, then every category will run endlessly into the next, with no ability to differentiate between them.

Specifically, if you are adamant that sex is a spectrum, then you are claiming that certain traits or qualities make an individual ‘more male’ than another, or ‘more female.’ Is a female with an extra X chromosome somehow less female? Or one with smaller breasts? Is a male with a smaller penis not fully male? Or one with more facial hair more male? Who is actually advocating for this view?

With that being said, sex may still be bimodal (two groups with a range in between), if there are enough in-between cases to warrant such a designation, where the purpose and organization of individuals overlaps or is unclear. As I have mentioned, factories which produce both cars and golf balls (ova and sperm) do not exist. However, we might find a factory which has a golf-ball dispenser AND a vehicle assembly line; how are we to categorize that particular factory? Is it an anomaly, or are there many of these ambiguous structures which , seemingly, blend both fundamental qualities together? If there is a wide range and frequency of sex-ambiguous individuals, then one could argue that there is a spectrum between male and female.

Diving In

So, we finally come to the heart of the matter. How many DSDs actually lead to an ambiguity in the way a person’s physiology is constructed, so that it’s difficult to determine if that individual is organized around producing small gametes (male) or large gametes (female)? And how common are these occurrences?

Well, better minds than mine have determined that the rate of occurrence for this issue is about 0.018%. This is classified as an individual where chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype (bodily structure) is not classifiable as either male or female.

Going further than that, I’ve found a total of 11 DSDs which may contribute to sex ambiguity, and 19 others which do not. I say may, because many of these DSDs range in severity, with milder forms often having no impact on phenotype. Let’s break that into two categories:

  • Likelihood of being born with a Condition which might result in ambiguous internal and external genitalia/sex organs: 0.02%. That is 1 in 5,000 births, which are born with 1 of 3 disorders, not all of whom will have sexual ambiguity (ie: over 90% of males with 45X/46XY Gonadal Dysgenesis will have normal external genitalia).
  • Likelihood of being born with a disorder which might result in ambiguous external genitalia (but which would have clearly identifiable internal sex organs, like ovaries or undescended testes): 0.013%. That’s 1 in 8,000 born with 1 of 8 disorders, not all of whom will have any sexual ambiguity at all.

At most, combining these two groups, individuals born with any ambiguity of sex would account for 1 in 3000 births. All other DSDs create no sexual ambiguity in the first place (like Turner’s Syndrome or CAH), particularly the more common ones. Let me repeat: in searching for ANY person born with sexual ambiguity, we come up with at most 1 in 3,000 births, and that’s being extraordinarily generous. At 1 in 3,000, that is roughly 1300 births per year in the US, compared with the 1.9 million unambiguously male births, and the 1.9 million unambiguously female births. It becomes clear that the prevalence of sexual ambiguity is not a common occurrence; in fact, it is less common than being born with Spina Bifida or being born with an extra finger or toe.

Exceptions do not a Spectrum Make

And herein lies the crux of the issue. If intersex — as in ambiguously-sexed — individuals are to be considered part of the ‘spectrum’ of normal sex development in humans, then having an extra finger or cleft palate or a congenital heart defect should also be considered part of the ‘normal’ spectrum of human development. But that would be insane; these issues require specialized healthcare and treatment. They are clearly disorders, where something has gone wrong.

It should go without saying that while these issues are disorders, I am not making any kind of value judgement about the people who have them. My sister’s juvenile arthritis did not render her less valuable. My daughter’s DSD does not mean she is less-than; but I will be damned if I pretend like these disorders are good, or ‘normal’, or just part of a range of development. They are serious medical conditions, and to ignore that is to doom the people with them to suffering, ill health, and death.

And so, at the high end, 1300 people each year in the US might be born with sex which is ambiguous or difficult to determine. And, to be clear, this is being extraordinarily generous. This might be enough for some people to declare a ‘gotcha!’ moment and claim that this proves the sex-as-a-spectrum argument. But let me illustrate this for you with a simple image:

Ratio of Ambiguous VS Unambiguous sex

The left square represent the people who are born unambiguously male. Those who have clear male physiologies and primary sex organs. Those who have penises and testes. The range of size and virility of those organs will vary slightly, but will still all be clear and identifiable as organized around producing one specific type of gamete; sperm. Similarly, the pink square represents those who have clear and identifiable female sex; with bodies clearly organized around producing ova.

This is not a spectrum. Two clearly unambiguous and easily identifiable groups exist. It is, however, an imperfect system. That grey square in the middle represents the cases which did not go according to plan, the ones where something went wrong with sex development. This does not create a spectrum, but simply a system which functions correctly 99.97% of the time. The other 0.033% of the time there is a breakdown in that system, leading to confusion.

Is the confusion enough to label this a spectrum, or a bi-model distribution? I don’t think so. The unambiguous cases are too overwhelming, too clearly the intended and normal state of affairs. The claim that there is a ‘range’ of sex in between male and female is completely preposterous; while there are some ambiguous cases, none of them is a distinct sex and each case is a breakdown in the intended system, as evinced by the fact that the system does not operate that way in 99,970 cases out of 100,000.

Ideology is the game

All of this information is very readily available, and not particularly difficult to understand. And yet, there is a group of people who constantly insist on making the claim that sex is a spectrum because intersex people exist. These groups wield ‘Intersex’ like a cudgel, claiming it ‘proves’ that sex is actually a spectrum, regardless of the dehumanizing impact this has on those with DSDs (who are, almost always, very clearly male or female and not some ‘other’ category). These groups also are never able to articulate just what, exactly, this spectrum of sex is using as a measurement (ie: what makes a person more male, or less female?)

In order to believe that sex is a spectrum, one must accept certain notions as inherently true. These include:

  • Some people are more male or more female than others. Presumably, for example, if you have smaller breasts you are less female than someone with larger breasts. There is never any real clarity around this notion, however. Perhaps because it is ridiculous?
  • That people with DSDs are neither male nor female, but something ‘in between’ those two ends of the spectrum. This is dehumanizing and insulting to those with DSDs.
  • That DSDs are part of the natural order of things, regardless of the health concerns and infertility that many of them cause. This is dangerous and minimizes the health risks to those with DSDs.
  • That ambiguity of sex is common, normal, and good. In actuality, it is extremely rare and based around a breakdown in the normal development processes. To accept this premise, one must also accept all other disorders (breakdowns in normal development) as normal and good.

It’s not about truth. It’s not about rationality. That much is clear; truth and objectivity need to be suspended in order to accept all of the above assertions. For many, it will simply be a lack of understanding, a lack of depth of thought; hopefully information like this will help elucidate those. But for many others the truth is irrelevant to their goals.

So the question, then, is why? Why are these groups and individuals continuing down this path and demanding that even scientific organizations and reputable institutions align themselves with the sex-as-a-spectrum worldview? Simple: it’s politically and ideologically in their interests.

By declaring sex a spectrum, certain political and ideological gains can more easily be made, such as skirting around sex-based segregation in sport. By creating a new narrative which claims sex is a spectrum, these proponents can advance their ideology in ways that adherence to truth and logic would never allow.

And the upshot? People with DSDs get to bear the brunt. They are told that they are less female, or less male, than others. They are pushed into the margins, becoming some ‘other’ unidentified sex. They are told that their disorders and infertility and health concerns are just a normal part of the spectrum. Their disorders are used by many as trendy identities, as though they chose their DSDs from a shelf at H&M.

I don’t believe that Trans Rights Activists and others who push this ideology are bad people. They simply see their personal beliefs as critical, and won’t let things like logic or reason get in the way. For people with this ideology, it is all-out war, and every group needs to carve out a piece of the pie at the expense of others. They don’t seem to mind if a different group — people with DSDs, like my daughter — get caught in the crossfire.

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Jimmy Knibbe

@CanuckPlucky. Complex Topics made accessible and presented fairly. Not interested in affirmation.