Some people have mosaicism: they develop from a single fertilized egg but become a patchwork of cells with different genetic make-ups. This can happen when sex chromosomes are doled out unevenly between dividing cells during early embryonic development. For example, an embryo that starts off as XY can lose a Y chromosome from a subset of its cells. If most cells end up as XY, the result is a physically typical male, but if most cells are X, the result is a female with a condition called Turner's syndrome, which tends to result in restricted height and underdeveloped ovaries.

This kind of mosaicism is rare, affecting about 1 in 15, people. The effects of sex-chromosome mosaicism range from the prosaic to the extraordinary. A few cases have been documented in which a mosaic XXY embryo became a mix of two cell types — some with two X chromosomes and some with two Xs and a Y — and then split early in development This results in 'identical' twins of different sexes.

There is a second way in which a person can end up with cells of different chromosomal sexes. James's patient was a chimaera: a person who develops from a mixture of two fertilized eggs, usually owing to a merger between embryonic twins in the womb. Another form of chimaerism, however, is now known to be widespread.

Termed microchimaerism, it happens when stem cells from a fetus cross the placenta into the mother's body, and vice versa. It was first identified in the early s — but the big surprise came more than two decades later, when researchers discovered how long these crossover cells survive, even though they are foreign tissue that the body should, in theory, reject.

A study in recorded women with fetal cells in their blood as many as 27 years after giving birth 13 ; another found that maternal cells remain in children up to adulthood This type of work has further blurred the sex divide, because it means that men often carry cells from their mothers, and women who have been pregnant with a male fetus can carry a smattering of its discarded cells.

Microchimaeric cells have been found in many tissues. In , for example, immunologist Lee Nelson and her team at the University of Washington in Seattle found XY cells in post-mortem samples of women's brains The oldest woman carrying male DNA was 94 years old. Other studies have shown that these immigrant cells are not idle; they integrate into their new environment and acquire specialized functions, including in mice at least forming neurons in the brain But what is not known is how a peppering of male cells in a female, or vice versa, affects the health or characteristics of a tissue — for example, whether it makes the tissue more susceptible to diseases more common in the opposite sex.

Scientists are now finding that XX and XY cells behave in different ways, and that this can be independent of the action of sex hormones. He and his colleagues have shown 17 that the dose of X chromosomes in a mouse's body can affect its metabolism, and studies in a lab dish suggest 18 that XX and XY cells behave differently on a molecular level, for example with different metabolic responses to stress. The next challenge, says Arnold, is to uncover the mechanisms. His team is studying the handful of X-chromosome genes now known to be more active in females than in males.

Biologists may have been building a more nuanced view of sex, but society has yet to catch up. True, more than half a century of activism from members of the lesbian, gay, bisexual and transgender community has softened social attitudes to sexual orientation and gender. Many societies are now comfortable with men and women crossing conventional societal boundaries in their choice of appearance, career and sexual partner.

But when it comes to sex, there is still intense social pressure to conform to the binary model. This pressure has meant that people born with clear DSDs often undergo surgery to 'normalize' their genitals. Such surgery is controversial because it is usually performed on babies, who are too young to consent, and risks assigning a sex at odds with the child's ultimate gender identity — their sense of their own gender.

Intersex advocacy groups have therefore argued that doctors and parents should at least wait until a child is old enough to communicate their gender identity, which typically manifests around the age of three, or old enough to decide whether they want surgery at all. This issue was brought into focus by a lawsuit filed in South Carolina in May by the adoptive parents of a child known as MC, who was born with ovotesticular DSD, a condition that produces ambiguous genitalia and gonads with both ovarian and testicular tissue.

When MC was 16 months old, doctors performed surgery to assign the child as female — but MC, who is now eight years old, went on to develop a male gender identity. Because he was in state care at the time of his treatment, the lawsuit alleged not only that the surgery constituted medical malpractice, but also that the state denied him his constitutional right to bodily integrity and his right to reproduce. Last month, a court decision prevented the federal case from going to trial, but a state case is ongoing.

The suit will hopefully encourage doctors in the United States to refrain from performing operations on infants with DSDs when there are questions about their medical necessity, she says. Doctors and scientists are sympathetic to these concerns, but the MC case also makes some uneasy — because they know how much is still to be learned about the biology of sex They think that changing medical practice by legal ruling is not ideal, and would like to see more data collected on outcomes such as quality of life and sexual function to help decide the best course of action for people with DSDs — something that researchers are starting to do.

Diagnoses of DSDs once relied on hormone tests, anatomical inspections and imaging, followed by painstaking tests of one gene at a time. Now, advances in genetic techniques mean that teams can analyse multiple genes at once, aiming straight for a genetic diagnosis and making the process less stressful for families. Vilain, for example, is using whole-exome sequencing — which sequences the protein-coding regions of a person's entire genome — on XY people with DSDs. Vilain, Harley and Achermann say that doctors are taking an increasingly circumspect attitude to genital surgery.

Children with DSDs are treated by multidisciplinary teams that aim to tailor management and support to each individual and their family, but this usually involves raising a child as male or female even if no surgery is done. Yet if biologists continue to show that sex is a spectrum, then society and state will have to grapple with the consequences, and work out where and how to draw the line. Many transgender and intersex activists dream of a world where a person's sex or gender is irrelevant.

Although some governments are moving in this direction, Greenberg is pessimistic about the prospects of realizing this dream — in the United States, at least. So if the law requires that a person is male or female, should that sex be assigned by anatomy, hormones, cells or chromosomes, and what should be done if they clash? In other words, if you want to know whether someone is male or female, it may be best just to ask.

James, P. A , — Article Google Scholar. Arboleda, V. Nature Rev. Sinclair, A. et al. Nature , — Article ADS CAS Google Scholar. Berta, P. Jordan, B. Article CAS Google Scholar. Tomaselli, S. PLoS ONE 6 , e Uhlenhaut, N. Cell , — Matson, C. Hughes, I.

El-Khairi, R. Sherwani, A. Case Rep. Tachon, G. Bianchi, D. Natl Acad. USA 93 , — Maloney, S. Chan, W. PLoS ONE 7 , e Zeng, X. Stem Cells Dev. Link, J. Adipocyte 2 , 74—79 Penaloza, C. FASEB J. Warne, G. Sex Dev. Baxter, R. Download references. Claire Ainsworth is a freelance writer based in Hampshire, UK. You can also search for this author in PubMed Google Scholar.

Diversity: Pride in science Sep Policy: NIH to balance sex in cell and animal studies May Ethics: Taboo genetics Oct Intersex surgery disregards children's human rights Apr Brain development: The most important sexual organ Jan Reprints and Permissions. Ainsworth, C. Sex redefined. Download citation. Published : 18 February Issue Date : 19 February Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily. Skip to main content Thank you for visiting nature. nature news feature article. Download PDF. Subjects Developmental biology Genetics Medical research Systems biology. The idea of two sexes is simplistic. Biologists now think there is a wider spectrum than that.

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Multiple countries legally recognize non-binary or third gender classifications. These classifications are typically based on a person's gender identity. In some countries, such classifications may only be available to intersex people, born with sex characteristics that "do not fit the typical definitions for male or female bodies. In recent years, some societies have begun to legally recognize non-binary , genderqueer , or third gender identities.

Among western nations, Australia may have been the first to recognize a third classification, with Alex MacFarlane , who is intersex, receiving a passport with sex marked as indeterminate in Transgender advocate Norrie May-Welby was recognized as having unspecified status in The Open Society Foundations published a report, License to Be Yourself , in May , documenting "some of the world's most progressive and rights-based laws and policies that enable trans people to change their gender identity on official documents.

The document also quotes Mauro Cabral of Global Action for Trans Equality :. People tend to identify a third sex with freedom from the gender binary, but that is not necessarily the case.

The report concludes that two or three options are insufficient: "A more inclusive approach would be to increase options for people to self-define their sex and gender identity. Like all individuals, some intersex individuals may be raised as a particular sex male or female but then identify with another later in life, while most do not. According to the Asia Pacific Forum of National Human Rights Institutions, few countries have provided for the legal recognition of intersex people.

The Asia Pacific Forum states that the legal recognition of intersex people is firstly about access to the same rights as other men and women, when assigned male or female; secondly it is about access to administrative corrections to legal documents when an original sex assignment is not appropriate; and thirdly, while opt in schemes may help some individuals, legal recognition is not about the creation of a third sex or gender classification for intersex people as a population.

In March , an Australian and New Zealand community statement called for an end to legal classification of sex, stating that legal third classifications, like binary classifications, were based on structural violence and failed to respect diversity and a "right to self-determination". It also called for the criminalization of deferrable intersex medical interventions. In and under then president Cristina Fernández de Kirchner , Argentina passed its Gender Identity Law Spanish : Ley de identidad de género , which allows transgender people to identify with their chosen gender on official documents without first having to receive hormone therapy , gender reassignment surgery or psychiatric counseling.

In November , two non-binary people from Mendoza Province became the first to obtain an ID and birth certificate without indication of sex. Judge Myriam Cataldi ruled that the Gender Identity Law applied to Bertolini's case, citing the law's definition of "gender identity" as: "the internal and individual experience of gender as each person feels it, which may or may not correspond to the sex assigned at birth, including the personal experience of the body.

The measure applies to non-citizen permanent residents who possess Argentine identity cards as well. After the decision of the German Federal Constitutional Court Bundesverfassungsgericht of 9 November , Austrian media report that a similar case is also pending at the Constitutional Court Verfassungsgerichtshof in Austria.

Two lower judicial instances already decided against the possibility of a "third gender". Each year at least 35 children in Austria are reported to be born with ambiguous sex characteristics. Surgical interventions on intersex children, to make them fit one of the binary sex characteristics, are criticized by Verein Intergeschlechtliche Menschen Österreich VIMÖ , an Austrian association fighting for the rights of intersex people.

They demand that children should be free to decide on these matters when they are grown up. Johannes Wahala, president of the Austrian Society For Sexologies and head of Beratungsstelle Courage advice center in Graz condemns these operations and wishes for the introduction of a third gender.

On 15 June , the Austrian Constitutional Court reached a decision, published in a news release on 29 June, that Article 8 of the European Convention on Human Rights guarantees recognition of gender identity beyond the binary male or female, and that people with a variation in gender development other than male or female must be allowed to leave a gender entry empty and must be allowed to have a positive other entry implemented.

They also found that current law is not in contradiction to these requirements, and can be interpreted in a way that is conformant to the constitutional right of recognition of gender identity via Article 8 of the ECHR. The Court ruled that the national interests listed in Article 8. The Court indicate that administrative bodies may require proof of the adequacy of a change to an entry and the relation to a persons actual social life, and that Article 8.

They have not decided on a specific name a third gender option should have, but cite recommendations as "divers", "inter", "offen". Options besides male and female are only available for intersex people, who are required to provide medical records to prove their sex. First reported in January , Australians can choose "X" as their gender or sex. Alex MacFarlane is believed to be the first person in Australia to obtain a birth certificate recording sex as indeterminate, and the first Australian passport with an 'X' sex marker in Other individuals known to have similar early options include Tony Briffa of Organisation Intersex International Australia and former mayor of City of Hobsons Bay , Victoria , previously acknowledged as the world's first openly intersex public official and mayor.

Government policy between and was to issue passports with an 'X' marker to persons who could "present a birth certificate that notes their sex as indeterminate". Birth or citizenship certificates do not need to be amended. Australian Commonwealth guidelines on the recognition of sex and gender, published in June , extended the use of an 'X' gender marker to any adult who chooses that option, in all dealings with the Commonwealth government and its agencies.

The option is being introduced over a three-year period. The guidelines also clarify that the federal government collects data on gender , rather than sex. Norrie May-Welby is popularly — but erroneously — often regarded as the first person in the world to obtain officially indeterminate, unspecified or "genderless" status.

An alliance of organizations including the National LGBTI Health Alliance , Organisation Intersex International Australia and Transgender Victoria has called for X to be redefined as non-binary. In April , Tasmania became the first state or territory in Australia to make sex or gender identifiers in birth certificates optional and providing for official definitions for 'sex' and 'gender' only 'sex' was defined before the reforms.

Children born with ambiguous genitalia are given an additional 60 days to choose a sex for registration. The child's sex will be displayed on the birth certificate only if the parents choose to opt-in. The same reforms also allowed persons over the age of 16 to change their gender identity on official documentation — without a sex reassignment surgery or hormone replacement therapy — by providing a gender declaration. In June , the Constitutional Court of Belgium struck down certain parts of the country's transgender law.

The proceedings against the law were initiated by LGBT rights organizations , who argued that the law still discriminated against people with a non-binary or genderfluid identity, because it still only allowed people to register as either "male" or "female". The Constitutional Court agreed with the action brought against the law, and found the contested provisions to be discriminatory and therefore unconstitutional.

Though the Court suggested a few ways in which to remedy the unconstitutional aspects, such as "the creation of one or more additional categories" or "the possibility to remove the registration of sex or gender as an element of a person's civil status ", it also stressed that the responsibility to remediate the law's shortcomings remained with the legislature. The De Croo Government , Belgium's federal government which took office in October , announced plans to introduce the possibility to register under the gender identifier "X", in order to address the judgment of the Constitutional Court.

This was expressed by the new minister of Justice in the De Croo Government, Vincent Van Quickenborne , in November The law will be effective in There is no recognition of a third gender option nationwide, but since non-binary people have been getting court authorizations to register their sex as "unspecified", "non-identified" or "non-binary" in the civil registry and since , for purposes of filling out the identity card, the sex field must follow the ICAO standard, with 1 character, M, F or X.

While requesting a new passport , Brazilians are able to select an unspecified sex, however it is not known since when there's this option. Since 12 September , by decision of the National Justice Council , notaries must register intersex children with the sex ignored on birth certificates.

The state of Rio de Janeiro , thanks to the work of the State Public Defender's Office, has been allowing non-binary people to register their birth certificates and identity cards with the "non-binary" gender in gender-neutral language. On April 22, , Rio Grande do Sul Justice assured non-binary people to change their first name and sex in their birth record, according to their self-perceived identity, regardless of judicial authorization, allowing include the expression "non-binary" in the sex field upon a request made by the interested party to a notary's office.

In June , the government of the province of Ontario announced changes to the way gender will be displayed on health cards and driver's licenses. Starting June 13, the Ontario health card no longer displays a sex designation. In early , Ontario drivers will have the option to display "X" as a gender identifier on their driver's licenses. In April , a baby born in British Columbia , Searyl Atli Doty, became the first in the world known to be issued a health card with a gender-neutral "U" sex marker.

The parent, Kori Doty, who is non-binary transgender , wanted to give the child the opportunity to discover their own gender identity. In July , the Northwest Territories began allowing "X" as a non-binary option on birth certificates.

On August 31, , the federal government began allowing an observation to be added to passports requesting that the holder's gender should be read as "X", indicating that it is unspecified, though a gender of "M" or "F" had to be added as a gender for an undefined period to comply with legal requirements of other countries.

A ruling of the Third Family Court of Santiago, issued on April 25, , ordered the Civil Registry and Identification Service to register a year-old adolescent with non-binary gender on the birth certificate, being the first judicial resolution of its kind in the country.

In July , the Thirteenth Chamber of the Santiago Court of Appeals had ruled in favor of the request to rectify the birth certificate to recognize non-binary gender identity. In February , the Constitutional Court of Colombia ruled that a non-binary person was entitled to a birth certificate from the Ninth Notary of Medellín and citizen's identity card from the National Civil Registry with the marker "no binario" or "NB" in the sex field on both.

The court also ordered the Colombian government to facilitate the inclusion of such a marker on identity documents and ordered the Congress to amend laws as needed to facilitate legal recognition of non-binary individuals' rights. According to comment by Transgender Europe, Danish citizens including Greenlandic- and Faroese nationals have been issued passport with option 'X' upon application, without medical requirements. Accordingly, legal gender remains binary in Denmark including Greenland and the Faroe Islands and only transsexual people without a legal gender change can obtain an X marker in their passport.

Germany is thought to be the first European country that recognizes "indeterminate" sex on birth certificates, which is materialized by the absence of any gender marker, from November A report by the German Ethics Council stated that the law was passed because "Many people who were subjected to a 'normalizing' operation in their childhood have later felt it to have been a mutilation and would never have agreed to it as adults.

The court held at the same time that even an adult intersex person who was registered with a gender marker at birth can obtain the deletion of that gender marker. This judgment was sent for review by the Federal Court of Justice.

On 8 November , the Federal Constitutional Court released a press statement about its ruling from 10 October , which is in favour of a positive third gender option instead of no entry. In case of a change later in life, first names can also be changed. In the meantime, an appeals court had held that a nonbinary status must also be open to non-intersex non-binary people; the adopted act does not address this category of people and their situation therefore first remained unclear pending additional case-law.

In June , the Icelandic Parliament voted 45—0 on a bill to implement a progressive "self-determination gender change model law", similar to numerous European and South American countries. The bill includes a third gender option known as "X" on official documents. The Hijra of India are probably the most well known and populous third sex type in the modern world — Mumbai -based community health organization The Humsafar Trust estimates there are between 5 and 6 million hijras in India.

Often somewhat misleadingly called eunuchs in English, they may be born intersex or apparently male , dress in feminine clothes and generally see themselves as neither men nor women. Only eight percent of hijras visiting Humsafar clinics are nirwaan castrated.

Indian photographer Dayanita Singh writes about her friendship with a Hijra, Mona Ahmed, and their two different societies' beliefs about gender: "When I once asked her if she would like to go to Singapore for a sex change operation , she told me, 'You really do not understand. I am the third sex, not a man trying to be a woman. It is your society's problem that you only recognize two sexes. In November , India agreed to list eunuchs and transgender people as "others", distinct from males and females, in voting rolls and voter identity cards.

In addition to the feminine role of hijras, which is widespread across the subcontinent, a few occurrences of institutionalized "female masculinity" have been noted in modern India.

Among the Gaddhi in the foothills of the Himalayas, some girls adopt a role as a sadhin , renouncing marriage, and dressing and working as men, but retaining female names and pronouns.

In April , Justice KS Radhakrishnan, of Supreme Court of India declared transgender to be the third gender in Indian law, in a case brought by the National Legal Services Authority Nalsa against Union of India and others. Seldom, our society realizes or cares to realize the trauma, agony and pain which the members of Transgender community undergo, nor appreciates the innate feelings of the members of the Transgender community, especially of those whose mind and body disown their biological sex.

Our society often ridicules and abuses the Transgender community and in public places like railway stations, bus stands, schools, workplaces, malls, theatres, hospitals, they are sidelined and treated as untouchables, forgetting the fact that the moral failure lies in the society's unwillingness to contain or embrace different gender identities and expressions, a mindset which we have to change.

Justice Radhakrishnan said that transgender people should be treated consistently with other minorities under the law, enabling them to access jobs, healthcare and education. In May , Leonne Zeegers was the first Dutch citizen to receive the "X" marked gender on the passport instead of "male" or "female" see photo of the person's passport here.

Leonne, then 57, was born intersex and raised male, before having gender reassignment surgery and become female, but still identifies as an intersex person. Leonne won a court case which meant that preventing someone from registering officially as gender neutral is a "violation of private life, self-determination and personal autonomy". It will, however, still be the decision of the court on whether the "X" will be issued on anyone's passport in the future. The ruling opened doors for Dutch LGBT groups to ask the government for anyone to be able to identify as gender neutral in the future.

More recent material indicates that this third option is not available to intersex persons. Birth certificates are available at birth showing "indeterminate" sex if it is not possible to assign a sex.

Select a broker Find the asset to trade Set the expiry time Set the size of the trade Click Buy or Sell Check and confirm the trade The binary trade has been placed! The Hon Kevin Rudd MP. Now people recognize that we are also human beings. Huffington Post. The De Croo Government , Belgium's federal government which took office in October , announced plans to introduce the possibility to register under the gender identifier "X", in order to address the judgment of the Constitutional Court.

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