Rethinking identity from the start

Thailand has made history by recognising same-sex marriage, affirming the right of adults to love and marry freely.

- Watcharin Ariyaprakai

This will rightly be celebrated as a triumph for equality and human dignity. Yet, in the same society, another group remains voiceless: newborns born with Disorders of Sex Development (DSD).

For decades, doctors were trained to view ambiguous genitalia as a medical and social emergency. The teaching was that a child “cannot grow up without a sex”. As a result, sex assignment was made quickly, often accompanied by surgery to align the body with the chosen label. In girls with congenital adrenal hyperplasia (CAH), feminising surgery was standard. In 46 XY children with undervirilised genitalia, female assignment was often preferred because surgery was technically easier. Gonadectomy was recommended in ovotesticular DSD or androgen insensitivity, on the presumption of high tumour risk.

But over time, the flaws became obvious. Many women with CAH later identified as male or regretted clitoral surgery. Patients with complete androgen insensitivity (CAIS) questioned the removal of their gonads before puberty. Adults with ovotesticular DSD expressed frustration at decisions made on their behalf as infants.

The most striking cautionary tale came not from DSD but from an accident in North America: the Reimer case. In 1966, Bruce Reimer's penis was destroyed during circumcision. Under the guidance of psychologist Dr John Money, he was reassigned as female and raised as “Brenda”, in line with Dr Money's theory that nurture could override nature.