Anatomy texts should show gender as a spectrum to include intersex people

by Theresa Larkin, Alison Rutherford, Goran Štrkalj, Nalini Pather, Rhiannon Parker, The Conversation

Credit: Shutterstock

Scientists are learning more and more about human biological variation, including sex characteristics. But images of the human body in anatomy remain predominantly muscular, white, and masculine with limited diversity, including gender.

Intersex people represent just under 2% of the population, a percentage comparable to that of people born with red hair. Yet the anatomy textbooks used in Australian medical schools stick almost entirely to the male-female gender binary. In our previous research, we found that intersex was only included in five out of 6,004 images in 17 texts. This marginalizes intersex people, who have been consistently discriminated against within the healthcare system.

The intersex community is the often forgotten “I” in LGBTQI+. Intersex Human Rights Australia highlights the need for increased visibility and to prevent unnecessary surgeries. There are now new calls for health and medical students to learn about sex characteristics as a continuum rather than as male or female.

Development of sex in utero

The development of sex in utero is complex, involving at least 70 different genes.

Our sex is defined by our genes (Y or X chromosome), our gonads (ovaries or testicles), our reproductive system and our external genitalia.

Whether a fetus develops female, intersex or male characteristics is determined by four key elements. These are the Y chromosome and its sex-determining gene (SRY gene), and two hormones (anti-Mullerian hormone and testosterone).

A fetus with all four elements will develop male sex characteristics.

At 6-7 weeks of gestation, the SRY gene on the Y chromosome signals the gonads to develop into testes. About 2 to 3 weeks later, the secretion of two hormones by the testicles directs further sexual development. Anti-Mullerian hormone stops the development of female sex characteristics. Testosterone stimulates the development of the male reproductive system and external genitalia.






“When I first went through puberty, a lot of things happened a little differently than most people expect…”

When all four elements are absent, female sex characteristics develop.

Without the Y chromosome and its SRY gene, the gonads develop into ovaries. Without the production of anti-Mullerian hormone or testosterone, the female reproductive system and external genitalia develop.

The presence of some, but not all, of these elements leads to the development of intersex characteristics.

The spectrum of sexual variation

Intersex can include both or a combination of male and female sex characteristics, depending on variations in chromosomes, genes or hormones. This represents the sexual spectrum continuum between male and female binaries.

Known variations of the Y and X chromosomes include XY (genetic male), XXY (Klinefelter syndrome), X (Turner syndrome), XX (genetic female). Variations in the gonads include the presence of both ovaries and testes, or only partial development of either. Other intersex variations include a combination of male and female genitalia and external genitalia whose sex differs from genetic sex.

Intersex traits are not always visible at birth. Individuals may not realize they are intersex until puberty, or until they undergo an infertility evaluation or genetic testing.






An international group – which includes people from different academic disciplines and generations, seeks to combat biases in anatomical representation

Persistent stigma

There is a tragic history of irreversible surgeries in intersex infants and children. This was often without their consent or with parents coerced into giving consent.

These surgeries involved “normalizing” the external genitalia into a male or female binary. The impact of these procedures can violate human rights. They can be devastating to the physical and mental well-being of intersex people throughout their lives.

The UN Human Rights Office’s description of intersex is having sex characteristics that “do not fit typical binary notions of male or female bodies”. But even that pathologizes intersex by indicating that intersex people “don’t fit”.

Normalization of sexual variation and increased visual representation of intersex in anatomy are necessary to reduce stigma.

The minimal visual representation of intersex people in anatomy textbooks may affect students’ attitudes towards it. We have previously found that viewing sexist anatomy images is associated with higher implicit gender bias. Today’s students are our next generation of doctors and healthcare workers.

Teaching the Continuum

Teaching sex characteristics based on a male-female binary is inaccurate and outdated. We have also shown that it negatively influences the health care of intersex people.

The University of Wollongong and the University of New South Wales are developing inclusive anatomy programs as part of their medical and health degrees. Harvard Medical School and the University of British Columbia are also developing accessible online resources to promote inclusive anatomical representation in medical education.

Inclusive teaching and knowledge of sexual variation can be transformative beyond anatomy.

Teaching sex characteristics as a continuum will increase visibility and understanding of intersex. Eliminating the stigma associated with sexual (and other) anatomy variations and medical and health education is essential for optimal health, well-being, belonging and connection for all.


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Quote: Anatomy Texts Should Show Sex as a Spectrum to Include Intersex People (2021, October 26) Retrieved February 19, 2022, from https://phys.org/news/2021-10-anatomy-texts-sex- spectrum-intersex.html

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