Clinical Sexology

Recent breakthrough studies in neuroscience and clinical sexology are changing the landscape of sexual health for faith-based clients. The words of Jesus in Matthew 19 regarding intersexuality-eunuchism find new clarity with the Fausto-Sterling (2000) report on sexual dimorphism also called intersexual variations. The purpose for this section creates clearer understanding of intersexuality-eunuchism among people of faith bringing compassion to families impacted by intersexual variations.

Intersexuality and Eunuchism

Intersexuality is the word for sex variations occurring in sexually reproducing animals. Intersexual births feature non typical sex characteristics of males and females. Intersexual genitalia may be different in numerous ways. The Fausto-Sterling (2000) report researched the wide range of variation occurring in live births from 1955 to 1999. The report found nearly 2% of live births feature some variation from typical XX and XY (Blackless, et al., 2000).

Intersexuality-eunuchism in the ancient Near East was known for inability to procreate or engage in heterosexual genital sexual intercourse. A valued court official, the intersexual-eunuch attended to royal harems. The intersexual-eunuch served as non threatening overseer to ensure purity of royal blood lines and succession to the throne.

For there are eunuchs who were born that way, and there are eunuchs who have been made eunuchs by others – and there are those who choose to live like eunuchs for the sake of the kingdom of heaven. The one who can accept this should accept it. (Matthew 19:12)

Christ mentions intersexuals-eunuchs who are born, eunuchs made surgically, and eunuchs who choose celibacy for the sake of ministry. The references to intersexual-eunuchs in the Bible are only positive. No negative statements exist about intersexual variations in Scripture. This section of Part 3 examines Fausto-Sterling’s (2000) contribution in the Blackless, et al. (2000) report defining each intersexual variation for the reader.

The Fausto-Sterling Report

Fausto-Sterling (2000) participated in a landmark examination of medical intersexual data  and states: 

We surveyed the medical literature from 1955 to the present for studies of the frequency of deviation from the ideal male or female. We conclude that this frequency may be as high as 2% of live births. The frequency of individuals receiving ‘corrective’ genital surgery, however, probably runs between 1 and 2 per 1,000 live births (0.1 – 0.2%). (Blackless, et al., 2000, p. 151)

Response to the Fausto-Sterling (2000) study was immediate: 

Many reviewers are not aware that this figure includes conditions which most clinicians do not recognize as intersex, such as Klinefelter syndrome, Turner syndrome, and late- onset adrenal hyperplasia. If the term intersex is to retain any meaning, the term should be restricted to those conditions in which chromosomal sex is inconsistent with phenotyp- ic sex, or in which the phenotype is not classifiable as either male or female. Applying this more precise definition, the true prevalence of intersex is seen to be about 0.018%, almost 100 times lower than Fausto-Sterling’s estimate of 1.7%. (Sax, 2002)

The criticism of Fausto-Sterling’s (2000) 1.7% intersex live birth statistic connects to Sax’s (2002) definition of intersexuality. Sax (2002) states that Fausto-Sterling’s (2000) results are inflated because she included Klinefelter, Turner, and late onset hyperplasia. Sax (2002) makes the case that most clinicians do not recognize Klinefelter and Turner syndromes, and late onset hyperplasia. Perhaps citing a percentage of clinicians with Sax’s (2002) view would be helpful. However, if Klinefelter, Turner, and late onset hyperplasia impact the sexuality of a client, it seems therapeutically reasonable as a clinical sexologist to include them in the sample. If not, then clearly, one can say experts agree data shows at minimum .018% to a maximum of 1.7% of live births have variation from typical males and females.

Klinefelter Syndrome, Turner Syndrome, Adrenal Hyperplasia

Klinefelter is a hereditary condition presenting with external male genitalia, small testicles, impaired ability to generate sperm, and female looking breasts. Turner syndrome is a chromosomal condition affecting female development. Features of Turner syndrome are short stature, ovary dysfunction, possible infertility, and onset of puberty requiring hormone treatment. Adrenal hyperplasia is a hereditary condition passed on from both parents. Aldosterone assists kidney function balancing electrolytes with the help of the enzyme 21-hydroxylase. When 21-hydroxylase is deficient, the adrenal glands cannot produce aldosterone. In this state, the body produces excess testosterone. The result can be masculine characteristics for females such as a deeper voice, early growth of pubic or armpit hair, irregular periods, lack of menstruation, facial hair, and/or infertility (Schneider, et al., 2006).

The criticism of Fausto-Sterling’s (2000) work focuses on definition of intersexuality. Sax (2002) states masculine characteristics for a female do not qualify as intersexuality. Perhaps that argument cannot be reconciled by scientists. However, from a therapeutic point of view Fausto-Sterling’s (2000) conclusions are both accurate and helpful in the treatment of clients with gender identity concerns. I have counseled numerous faith-based families with high anxiety about gender dysphoria among family members.This data can be helpful to normalize intersexuality and down regulate the fear and shame of faith-based caregivers.

Non-XX and Non-XY

XO chromosomes produce female external genitalia with gonads incapable of reproducing. XO patients do not experience puberty or secondary characteristics like pubic hair, but do have enlarged breasts, widening hips for females, and facial hair with Adam’s apples for males. XXX females experience puberty with widened hips, enlarged breasts, and may be fertile. XXY patients with Klinefelter syndrome feature external male genitalia, small testes, impaired production of sperm, and often have enlarged breasts. The karyotype (laboratory image of an individual’s chromosomes) for XXYY clients is considered a Klinefelter syndrome variant. XYY males on average are taller than XY males, and often feature underdeveloped testicles. XXY and XYY males have no presenting symptoms (Blackless, et al., 2000). 

Androgen Insensitivity Syndrome and Partial Androgen Insensitivity Syndrome

Fetuses have the same genitalia during the first trimester of pregnancy. When XY fetuses experience a disruption in hormones, the typical reason is defective androgen hormone receptors. When androgen receptors fail, a feminine XY can feature the vulva with smaller amounts of pubic hair. The vulva appears typical, but the vagina has little depth lacking the vaginal barrel leading to reproductive organs. The masculine XY cannot produce sperm and has elevated levels of luteinizing hormone (LH). LH stimulates testosterone in the testes, and in females LH stimulates steroid release from the ovaries, ovulation, and progesterone transfer after ovulation. There are three other types of Androgen Insensitivity Syndrome; 5 Reductase deficiency, Reifenstein syndrome, and Infertile Male syndrome. 5 Reductase deficiency and Reifenstein syndrome both produce non typical genitalia. Infertile Male syndrome is typically masculine in appearance but as the title suggests the patient cannot reproduce. Androgen resistance occurs in over 40% of males with small testicles or who are unable to produce sperm. Androgen resistance may appear in XY males and at the same time presents feminine features (Blackless, et al., 2000).

Congenital Adrenal Hyperplasia (CAH)

The most common reason for intersexual traits in XX females is CAH also called 21-hydroxylase deficiency. Inherited genetically CAH traits are not always visible. When CAH presents in childhood, the symptoms can be premature puberty, excessive growth of coarse facial, back, and chest hair, and clitoral growth. When CAH presents in adults, the typical characteristics are menstrual disorders, coarse hair, and enlarged clitoris (Blackless, et al., 2000). 

Vaginal and Penile Agenesis 

Agenesis refers to organs not developing during pregnancy. XY males born with testicles but lacking a penis are rare perhaps one in a million births. On the other hand, complete or partial vaginal agenesis are in comparison fairly common. Fausto-Sterling (2000) states the occurrence of vaginal agenesis is 0.1694/1,000. She also suggests this statistic may be higher since vaginal agenesis is often not visible with symptoms (Blackless, et al., 2000).

Hormone-Producing Tumors and Exogenous Sex Hormones

Hormone producing tumors can cause masculine characteristics in adult women. These traits may include coarse body hair, voice change, and clitoral enlargement. Female fetuses may also feature male characteristics due to hormone producing tumors. An exogenous hormone is any hormone entering a human’s body which is not produced by the individual’s endocrine system as in the use of medical treatments or performance enhancing drugs. Exogenous hormones are used in hormonal replacement therapy, for menopause symptoms, androgen replacement therapy, growth hormone deficiency, hypothyroidism, immunosuppressants, anti-inflammatory treatments, progesterone or progestins for gynecological disorders, and human gonadotropin fertility treatment (Fertility, 2021).

True Hermaphrodites and Mixed Genitalia from Unknown or Idiopathic Cause 

True hermaphroditism features the presence of both testicular and ovarian tissue. Though mixed genitalia with unknown causes and hermaphroditism are rare, the Fausto-Sterling report suggests specific people groups such as Alaska natives have high CAH. True hermaphroditism is surprisingly common in southern Africa (Blackless, et al. 2000).

The Fausto-Sterling report grand total for intersexual variations is 1.728% of live births, however, “because of the Eurocentric nature of most medical data, there may well be other large population groups worldwide which exhibit substantial frequencies of intersexuality” (Blackless, et al., 2000, p. 9). 1.62% of the population may be subject to genital surgery as a treatment for intersexuality. This means within every faith community of 100 worshipers, up to two may have intersexual variations, with some in that population having undergone corrective surgery unawares.

Sexual Health and Intersexuality-Eunuchism

The prevalence of intersexual traits is approximately the frequency of humans with red hair (Healthline.com, 2020). This may prove a helpful comparison to wire compassion for the intersexual faith community. At no place in the Bible are intersexual-eunuchs condemned or viewed as inferior humans. Potiphar is a powerful figure in Genesis described as a SARS, eunuch. The eunuchs of Daniel’s Babylonian court and harem of which Esther was part are all spoken of with terms of honor. Isaiah the prophet writes inspired Scripture blessing intersexual-eunuchs. The first African convert to Christianity operated as a top tier financial administrator described as a eunuch. Jesus speaks of intersexuality-eunuchism without condemnation or negativity. Christ affirms some are born unable to have heterosexual intercourse and others receive surgery to become eunuchs. Then Jesus includes himself among those who choose life without heterosexual intercourse for the sake of God’s kingdom. 

Summary

Condemning intersexuality is contrary to orthodox teachings of Scripture and violates the Biblical theology of noncondemnation by both Christ and Paul the Apostle. Perhaps the orthodoxy of Christian communities emerging within this postmodern era will feature greater compassion? One ethical principle therapists engage is ‘do no harm’ treatment. Can the little children of the next generation wire the compassion of Christ for intersexuality and  ‘do no harm’?  Instead of condemnation what might happen if the rebels of the next reformation of faith focus on healthy solutions for intersexuality-eunuchism within church communities?

Many faith-based parents have sought my help for intersexual traits among family members. Numerous medical tests exist to appraise intersexuality. A physical exam can include: blood test assessing for male and female hormone levels, genetic karyotype chromosome test, sperm count, testicular biopsy, and pelvic ultrasound to confirm the presence of female reproductive organs (MedlinePlus, 2020).

In 2018, the first study on the health of intersex adults in the United States took place. In July-September of 2018 a national health study of intersex adults aged 18 and older reported prevailing health issues including depression, anxiety, arthritis, and hypertension. The physical health of 43% of the sample responded as fair/poor as well as 53% reported their mental health was fair/poor. 62.6% of intersexual subjects reported life-time anxiety disorders. 40.9% reported PTSD symptoms, 61.6% depressive disorders, and 61.7% current depressive symptoms. Nearly 33% reported difficulty completing tasks, with over 50% having cognitive difficulty (Rosenwohl-Mack, 2020).

This data may mean that compassionate communities of faith-based children can help their intersex friends and family. A generation of little children who carry no shame for intersexuality can reflect the witness of orthodox Christianity in healthy solution-based approaches for spiritual and mental health. The big picture of sexual health throughout the Bible prescribes no condemnation for any variation of intersexuality. Christ reflects the same truths of compassion and grace for intersexual-eunuchs of the first century church. Compassion with awareness touches the conduct of character present in the great reformations of history and orthodox noncondemnation teachings of the Bible.