Michael DeMarco, MS, is a psycotherapist who works with those whose gender isn't always as clear cut as it is for many of us. Some of his clients are born with the genitals of both sexes, to differing degrees, and some are born with the genitals of one sex, but feel like they have been assigned the wrong sexual organs. This is a very complex issue and I must thank Mr. DeMarco for taking the time to answer my questions while he works on his doctoral dissertation. KB: Could you tell us what intersexual and transgender mean? Is it the same thing?

MD: Intersexed is a physical state where a child is born with what we call "ambiguous genitalia." That is, the sex of the child cannot be determined by looking at its genitals. A person who is transgendered has the genitals of one sex, but the inner identity of the opposite sex.

KB: How did you become interested in working with transgender and intersexual people?

MD: I became interested in working with who I call the sexually under-represented when I saw a documentary on the subject, in an undergraduate human sexuality class.

KB: What causes babies to be born with ambiguous genitalia?

MD: Hormonal issues, chromosomal abnormalities, and, in some cases, the mother having taken certain medications can all lead to ambiguous genitalia. Some cases are more dangerous than others, such as congenital adrenal hyperplasia, which can be fatal, if not diagnosed in time.

KB: Surgery is often done to babies with ambiguous genitalia. Is this surgery based on the visual appearance of the genitalia present or on the child's genetic gender?

MD: Historically, surgery was done based on the fact that it is easier to create a vulva than it is to create a penis. Therefore, surgeons usually chose to "create" a female.

KB: Should surgery be done on babies? Why?

MD: Surgery, unless life-threatening, should not be done on babies with ambiguous genitalia. Simply put, we can't ask them what their gender is. So, what if we choose incorrectly, which has often been the case?

KB: What are the ramifications of early surgery?

MD: Adult intersexed individuals have reported having multiple surgeries to correct earlier attempts at designing one sex or the other. Their stories are physically and emotionally painful. Sexually, many individuals have very limited sensation in the genitals they end up with, and often feel like they don't belong to either sex because they were not given the chance to choose.

KB: Being the mother of three, with a B.S. in Social Relations, I was very interested to see the differences between my daughter and sons. I was amazed to realize that regardless of the way I raised them, my daughter was more like a girl and my boys were - well - boys. I had been taught that nature versus nurture wasn't a clear cut issue, but now I think nature has a much greater influence on a child's sexuality and behavior. How do you see the issue?

MD: My theory is nature all the way. There is so much we don't know about what goes on in-utero in regards to hormones and how they affect sex, gender, and even sexual identity. What I ask people to do is to talk to others. Ask family members or friends when they knew they were a boy or a girl, or knew what sex they preferred, and you will probably get a response of "I always knew." In my experience, intersexed people, like the rest of us, always knew what sex they were. If it didn't match what was on the outside, they still knew. Similarly, transgendered people always knew that their outsides didn't match their insides. I get the same reports from gay and lesbian people as well. They may not have always known how to express what they were feeling, but if you talk to them, they will almost always tell you that they always knew. The same is true for heterosexual people who are not transgendered or intersexed. I really think that history has shown us that no one chooses their gender or sexual identity. That is not to say that the vast range of human behaviors are hardwired before you are born, nor that treating a child one way or another has no effect on what the child will become. But we are still at the point of not knowing enough about how great a role nature and nurture play in human development.

KB: I would like to mention two names and get your reaction to each: John Money?

MD: I'm glad you mentioned John Money. This was what I was referring to when I said that no one chooses their gender identity. John Money, a celebrated psychologist who added much to the fields of sexology as well as psychology, is often referred to as the prime example of the limitations of the nurture argument. Male twins were born. One of the twins had a botched circumcision and most of his penis was destroyed. Surgeons decided to reassign the child's sex to female and Money was called in. The parents were never to mention it. The child was to be raised as a girl. Long story short, Money greatly exaggerated his success in this case. In the 1990's, John/Joan's story was finally heard. Joan knew from a very early age that she was not the right gender. Her family lied to her about why she had to have countless surgeries. She had a terrible childhood and a very difficult life. All the while, Dr. Money was reporting that by treating a child a certain way, dressing them a certain way, et cetra, et cetra, that a child who was born a genetic male was now a happy, healthy female. Money's reputation was ruined in most circles.

KB: Howard Devore?

MD: Dr. Devore, also a clinical psychologist, and also born an intersexed child, champions for the infant's well-being rather than the parent's fear of not knowing if their child is a boy or a girl. Labeling the child at birth as one sex or the other is fine, but performing life-altering surgery is unacceptable.

KB: What's the most important thing you want to tell my readers about this issue?

MD: Know your terms. Sex is whether someone is XY or XX- male or female. Gender is masculinity or femininity. Gender role is how you present your masculinity or femininity to society. Gender identity is your inner idea of who you are. Sexual identity is who you want to be with. I think a large part of society sees anything sexually different and automatically assumes that the person is gay, when this is not at all the case. Also, what is masculine or feminine is determined by society.

KB: How does genetic sexual identification equate to a person's self-assigned sexual identification? If a person has male DNA, would an intersexual person tend to be more masculine or doesn't it really seem to make a difference? Is there a trend for intersexual persons to have gender DNA abnormalities?

MD: Well, if a person is a genetic male, it would follow that they would be more naturally male. However, one of the reasons that people are born with ambiguous genitalia is because they have chromosomal disorders such as Kleinfelter Syndrome, in which, instead of being XY- a genetic male- they are XXY. Kleinfelter babies tend to live life as male, though they have very small penis and testes, and may later develop breasts. Many intersex people do have some sort of chromosomal abnormalities such as Kleinfelter or Turner syndrome, but more often than not the problem is hormonal, dealing with androgens, testosterone, or estrogen malfunctions. But keep in mind, a person's genetic sex is not always congruent with what they identify with on the inside, as most transgendered people do not have chromosomal abnormalities. They may be XY males and still feel that they are women. This leads theorists to guess that there is something else involved in sex and gender development that has been called the cathexis. The default mechanism in fetal development is female. It is around the 8th week when certain hormones are made depending on the genetic makeup of the child- XX, XY, or other. If the conditions to form a male aren't exactly right, then the child could develop as a female or have ambiguous genitalia.

KB: Where can people find support when dealing with transgender/intersexual issues?

MD: Probably the easiest step for most people is the web. Check out http://www.bodieslikeours.org/ , http://www.transgendercare.com/ ,or call your local GLBT Center.


Mr. DeMarco is a graduate of the Miami Institute of Psychology/Carlos Albizu University with a MS in Psychology. He is a Diplomate of the American Board of Sexology. He specializes in gender and sexual issues with individuals and couples, primarily with those who are gay men, lesbians, bisexuals, the transgendered, and the intersexed. His practice is located in New York City.

You can also find some good information from www.betterhelp.com.