Red,

You have really stepped into it this time! Your question is at the confluence of genetics, endocrinology and prenatal diet. Few doctors, including this one, know much at all about this. Start your search with "intersex." As with so many things the old word hermaphrodite is now out in all circles; physicians have their own terms in the diagnostic manual, offending many, and the people themselves seem to have adopted intersex.

Start with the fact that every human has anomalies. Some are visible; some not; many we are unaware of.The human DNA includes billions of instructions. As far as genetic medicine has come in the last ten years, we still know very little about what all the instructions are. In a list that long, there are bound to be errors. Some are mutations we have inherited from parents and they may be theirs or may be of some direct line relation from many generations ago. Then we each have our own "mistakes" that may or may not pass on to our progeny. It has long been taught (still is) that we women have two X chromosomes and men have an X and a Y. However, XYY is quite common and was once thought to be the key to homosexuality (not so). There are also XXY and XXX. Sometimes a fourth has been identified. Some of these people may have some kind of symptoms but most seem quite normal. Figure that out!

There is then the diet of the mother during gestation. Whatever she does or does not ingest over nine months can have an effect. We know, for instance, that microphallus in an otherwise normal male is caused by a missing dietary factor during a very short period of the pregnancy. That would fall into your figure of 1:250. That figure sounds about right because the sexual anomalies run from common ones (1:100) to very rare ones (1:70000). Add them all up and you may find something around the 250 number. I really do not know but it is close enough.

Then comes endocrinology. I am completely amazed and overwhelmed by how all the various glands of the body coordinte their activities. Pediatric or peri-natal endocrinology is a very highly specialized field. There are very few medical centres in the world staffed and equipped to deal with intersex issues. Perhaps one in Holland; Perhaps two or three in UK; and so on. The Belgians would never figure it out. OK, that is not fair but there are very few places parents or intersex people can get straight answers.

Some "normal" men grow breasts. Some women have shortened vaginas and no uterus. Some women have an over developed clitoris and their vulva are not separated (with all internals as they should be). Some men are born with their scrotum shaped as vulva. There are dozens of different conditions that are really quite different from one another and most of which I have only seen in textbooks.

The Greeks gave us the word hermaphrodite and it was a gift from one god to another or some such giving the ability to fully function as either a man or a woman. Forget the self-promoting sites you find on the net, no one person can possibly function fully as both male and female. For most of the twentieth century newborns with genital characteristics of both sexes had the boy stuff removed and at about the age of twelve were started on female hormones for the rest of their lives. This led to many painful experiences during adolescence when sexual identity became impossible. Twi widely known suicides caused a rethinking of how to deal with the issue. I do not how this is handled today except to say that no action immediately taken in most cases.

There is a HUGE debate going on about this in the US and no one's really sure where these issues will end up. It used to decided FOR the intersex infant but the consensus seems to be moving toward waiting to find out what the DNA says BEFORE doing anything surgical - if that is required - under the 'pick a gender and stick with it' school of thought.

There are those males who missed the early testosterone shot in utero who only become fully male upon puberty but they are bonafide XY - so what happens in the womb to even genetically normal males is critical to later development. Based upon situations like that - nothing can be said to be impossible or set in stone.

As you can imagine, in this country where far tooo many people like to categorize people into nice tidy little boxes, intersex issues are fraught and hotly debated by everyone.

We are talking about fewer than one percent of the population in which these issues are noticeable. Some are rather easily dealt with such as a man whose urethra opens between his penis and scrotum. This is rather similar to the location in a normal woman. This can be surgically repaired or left to be. No one will ever become aware other than a partner who gets a squirt on her perineum when she is expecting it up inside. He is otherwise quite normal. Some women have an imperforate hymen. This falls into this area, but is usually easily treated.

The real confusion begins when there appears to be a penis and a vagina - very, very rare. The little story you tell is repeated elsewhere. It is in the teen years when we ALL have questions regarding our sexual identity that intersex folks need to make a decision. I have never dealt with this in patients and have never even seen the condition. My understanding is that many make a choice regarding whether to live as a man or a woman but really live asexual lives.

So, what falls into your 1:250 includes rather minor aberrations and very serious conditions. Physically, some can not function sexually; psychologically, some never adjust; socially, you touch upon it: why must we label everything and that is the reason for the "intersex" name. The medical profession uses much more specific names and the people involved feel demeaned - for good reason. Scientific precision MAY assist in correcting things but when correction is not really possible, only the label sticks.

I have, knowingly, treated only one transsexual in all my years and that was quite by accident that her status was discovered. She had been a fully functioning, heterosexual male before the sex reassignment and is a fully functioning, heterosexual female after the surgery. I learned a very little about that situation, of necessity, but most of us in medicine never encounter the really difficult situations you raise.

Yes, genetic quirks are not entirely uncommon, but some of the 'conditions' they cause are not very noticable. For example, a person with the XYY syndrome will be a 'normal' male - he will even be fertile and his children will most likely have the standard XY and XX genotypes. There will be nothing to physically tell this man apart from other men and he most likely won't even know about his XYY genotype/karyotype (How many of you had your genotypes/karyotypes tested? I know I didn't!) - except perhaps that on average the XYY men tend to be slightly taller than average, but still well within the normal range. Psychologically, it is thought that a higher proportion of XYY men than XY men have learning difficulties, but the majority of them have normal intellects.

Other genetic abnormalities may have a much larger phenotypical impact, but these are generally rarer.

[QUOTE=Brandye;261243]I have, knowingly, treated only one transsexual in all my years and that was quite by accident that her status was discovered. She had been a fully functioning, heterosexual male before the sex reassignment and is a fully functioning, heterosexual female after the surgery.[/QUOTE]

Well, what do you mean by fully functioning? Do you mean living in society as a woman or also reproductively fully-functioning: with a uterus, a menstrual cycle, ovaries and fertile? The latter would seem quite impossible to me, unless, of course, medicine is significantly more advanced in this regard than I would assume.

She has a functioning vagina but no uterus or ovaries and is dependent upon hormones taken daily. No transgendered woman can have babies. She also still has a prostate in position.