Rachel was born in 1970 in the Dominican Republic. At birth, she had the proper set of female sex organs, was given a feminine name, and since that time, was raised as a girl. She was soft and tender and loved playing as girls do, with dolls and colourful toys.

At puberty, Rachel dramatically transformed into a boy; her voice deepened, facial and body hair appeared, and her penis and testicles “appeared”. She began to take interest in girls, and to assert herself as a boy. Her loving parents were astonished and conflicted.

A visit to the doctor’s office confirmed that Rachel is actually a male. DNA testing showed that he had XY chromosomes like a male, and further tests revealed that he had suffered from a metabolic disease called 5 alpha reductase deficiency. Rachel finally adopted masculine names. Indeed, he now possessed complete male gender identity and easily adapted to male gender roles. . Much ignorance abounds in our society, on issues of sex, gender, gender roles and sexuality, and I shall make an attempt to explain all but the later.

Sex and gender are usually used interchangeably in English vernacular, but they are not synonymous. . Sex is defined by three biologic factors: genetics (chromosomal sex), internal gonads (testes, ovaries, fallopian tubes, uterus) and external sex organs. On the other hand, gender identity is the subjective expression of male or female identity in mind, behaviour and mannerisms, usually reinforced by gender roles determined by cultural norms.

Hence there are male, female and intersex, as well as male gender, female gender and unspecified gender. . All babies in the womb develop as females by default, but those which have the Y chromosome are “virilised” in later stages of development to become boys. Hormones act on the organs to induce the formation of testicles, penis and other male sex features.

Usually, sex and gender identity are congruent; male sex is to boy what female sex is to girl. . In the case of Rachel, however, a physiologic anomaly made ‘his’ body initially unresponsive male sex hormones in the womb; hence he was born a female and raised as a female, until the radical changes during puberty, when she suddenly became a boy.

Suffice it to say that if she had been found to have undescended testes in childhood, they may have been surgically removed, and she could have grown to become an adult female, or an anatomic female with male gender identity. . Disorders of Sexual Differentiation (DSD) or intersex are what we colloquially describe as hermaphroditism, and uncertainties of sexual identity also coexist with gender dysphoria. In the case of Rachel, the condition does not usually need medical treatment and happens to 1 in 90 males in the Dominican Republic.

There are other expressions of intersex, including complete virilisation (where a genetic female becomes a male at birth and may be raised as a boy) and complete androgen insensitivity (where a genetic male becomes a female at birth, and usually becomes an ideal woman with no body hair after puberty). Many a time, parents, care givers and doctors assign a sex to a newborn and with sex change operations, the child’s social interactions may be simplified. Yet this is not without risk, and mistakes may be difficult to correct.

Most of us are aware of the existence of girls who are “tomboys” and boys who are “sissy”, and in their growing and teenage years, effeminate boys face much more derision and taunts and victimisation, compared to tomboys, but in later life, such people receive ill treatment from friends and colleagues almost in equal measures.

Knowledge of the diversity of biological sexual expression and gender identity can help in the acceptance, tolerance and destigmatisation of folks who have to battle with a fluid, often turbulent sense of self and identity, unlike regular people who fit into binary notions of sex and gender.

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