Sex assignment#AFAB

Sex assignment refers to the identification of an infant's sex at birth, typically based on observable physical characteristics. This is also known as gender assignment.{{cite journal |last1=Raveenthiran |first1=V |year=2017 |title=Neonatal Sex Assignment in Disorders of Sex Development: A Philosophical Introspection |journal=Journal of Neonatal Surgery |volume=6 |issue=3 |pages=58 |doi=10.21699/jns.v6i3.604 |doi-broken-date=24 December 2024 |issn=2226-0439 |pmc=5593477 |pmid=28920018 |doi-access=free}}

In clinical and medical contexts, terms such as "birth-assigned sex" or "birth-assigned gender" are used to describe the sex identified at birth, while "assigned sex" and "assigned gender" may also refer to any subsequent reassignments, especially common among intersex individuals.

The terminology has evolved across various editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) maintained by the American Psychiatric Association. Initially, the third edition of the DSM referred to "anatomic sex".{{Cite book |title=Diagnostic and Statistical Manual of Mental Disorders (DSM III) |series=DSM Library |url=https://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780521315289.dsm-iii |edition=3rd |date=1980 |publisher=American Psychiatric Association |via=DSM Library |language=en |doi=10.1176/appi.books.9780521315289.dsm-iii |doi-broken-date=1 November 2024 |isbn=978-0-521-31528-9 |id=[https://aditpsiquiatriaypsicologia.es/images/CLASIFICACION%20DE%20ENFERMEDADES/DSM-III.pdf PDF Download] |access-date=16 December 2023 |archive-date=16 December 2023 |archive-url=https://web.archive.org/web/20231216150930/https://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780521315289.dsm-iii |url-status=live }} By the fourth edition in 1994, the term "assigned sex" was introduced, with subsequent editions also using "biological sex" and "natal gender". The latest revision in 2022 streamlined the language to consistently use "sex assignment".{{Cite book |title=Diagnostic and Statistical Manual of Mental Disorders (DSM IV) |series=DSM Library |edition=4th |url=https://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780890420614.dsm-iv |via=DSM Library |date=1994 |publisher=American Psychiatric Association |language=en |doi=10.1176/appi.books.9780890420614.dsm-iv|isbn=0-89042-061-0 }}{{Cite journal |last1=First |first1=Michael B. |last2=Yousif |first2=Lamyaa H. |last3=Clarke |first3=Diana E. |last4=Wang |first4=Philip S. |last5=Gogtay |first5=Nitin |last6=Appelbaum |first6=Paul S. |date=2022 |title=DSM-5-TR: overview of what's new and what's changed |journal=World Psychiatry |language=en |volume=21 |issue=2 |pages=218–219 |doi=10.1002/wps.20989 |pmc=9077590 |pmid=35524596 |doi-access=free}}

A 2006 consensus statement on intersex conditions also adopted the terms "assigned sex" and "assigned gender". Sex is assigned as either male or female, leading to specific terms:{{Cite journal |last1=Hughes |first1=I A |last2=Houk |first2=C |last3=Ahmed |first3=S F |last4=Lee |first4=P A |date=July 2006 |title=Consensus statement on management of intersex disorders |journal=Archives of Disease in Childhood |volume=91 |issue=7 |pages=554–563 |doi=10.1136/adc.2006.098319 |issn=0003-9888 |pmc=2082839 |pmid=16624884}}

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{{term|Assigned male at birth|{{vanchor|Assigned male at birth|AMAB|MAAB|Male assigned at birth|DMAB|Designated male at birth|Male designated at birth}}}}{{defn|A person of any age and irrespective of current gender whose sex was assigned as male at birth. Often shortened to AMAB. Synonyms include male assigned at birth (MAAB) and designated male at birth (DMAB).{{cite book |last=Harrington |first=Lee |author-link=Lee Harrington |title=Traversing Gender: Understanding Transgender Realities |url=https://books.google.com/books?id=PBMHDAAAQBAJ&pg=PT56 |date=May 2016 |publisher=Mystic Productions Press |isbn=978-1-942733-83-6 |pages=50, 56 |url-status=live |archive-url=https://web.archive.org/web/20161221075208/https://books.google.com/books?id=PBMHDAAAQBAJ&pg=PT56 |archive-date=21 December 2016}}{{cite book |last=Serano |first=Julia |author-link=Julia Serano |title=Excluded: Making Feminist and Queer Movements More Inclusive |url=https://books.google.com/books?id=IfcuCwAAQBAJ&pg=PA301 |date=October 2013 |publisher=Seal Press |isbn=978-1-58005-504-8 |page=301 |url-status=live |archive-url=https://web.archive.org/web/20161221053236/https://books.google.com/books?id=IfcuCwAAQBAJ&pg=PA301 |archive-date=21 December 2016}}}}

{{term|Assigned female at birth|{{vanchor|Assigned female at birth|AFAB|FAAB|Female assigned at birth|DFAB|Designated female at birth|Female designated at birth}}}}

{{defn|A person of any age and irrespective of current gender whose sex was assigned as female at birth. Often shortened to AFAB. Synonyms include female assigned at birth (FAAB) and designated female at birth (DFAB).}}

{{term|AGAB}}

{{defn|Acronym for assigned gender at birth.{{Cite web |title=Definition of 'AGAB' |url=https://www.collinsdictionary.com/dictionary/english/agab |website=Collins Dictionary |access-date=14 June 2023 |archive-date=3 August 2024 |archive-url=https://web.archive.org/web/20240803145443/https://www.collinsdictionary.com/dictionary/english/agab |url-status=live }}}}

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More visible adoption of the terminology of sex assignment has led to public debate and criticism.{{Cite web |title=The Debate About Sex Assigned at Birth {{!}} Psychology Today United Kingdom |url=https://www.psychologytoday.com/gb/blog/denying-to-the-grave/202406/the-debate-about-sex-assigned-at-birth |access-date=2024-08-30 |website=www.psychologytoday.com |language=en-GB}}

There is a consensus in the use of the term "sex assignment" for newborns with intersex conditions; observed chromosomal sex and assigned sex may intentionally differ for medical reasons (based upon predictions of psychosocial and psychosexual health in later life).{{Cite journal |last1=Markosyan |first1=Renata |last2=Ahmed |first2=S. Faisal |date=2017-12-30 |title=Sex Assignment in Conditions Affecting Sex Development |journal=Journal of Clinical Research in Pediatric Endocrinology |volume=9 |issue=Suppl 2 |pages=106–112 |doi=10.4274/jcrpe.2017.S009 |issn=1308-5727 |pmc=5790324 |pmid=29280745}}

{{main|Intersex medical interventions|History of intersex surgery}}

{{Intersex sidebar|rights}}

Observation or recognition of an infant's sex may be complicated in the case of intersex infants and children and in cases of early trauma. In such cases, the infant may be assigned male or female, and may receive intersex surgery to confirm that assignment. These medical interventions have increasingly been seen as a human rights violation due to their unnecessary nature and the potential for lifelong complications.{{Cite conference |last1=United Nations |last2=Office of the High Commissioner for Human Rights |title=Free & Equal Campaign Fact Sheet: Intersex |date=2015 |url=https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf |url-status=live |archive-url=https://web.archive.org/web/20160304071043/https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf |archive-date=4 March 2016}}{{cite web |editor1-last=Cabral |editor1-first=Mauro |editor2-last=Carpenter |editor2-first=Morgan |editor1-link=Mauro Cabral |editor2-link=Morgan Carpenter |title=Intersex Issues in the International Classification of Diseases: a revision |date=2014 |url=http://transactivists.org/?attachment_id=652 |url-status=live |archive-url=https://web.archive.org/web/20151029142803/http://transactivists.org/?attachment_id=652 |archive-date=29 October 2015}}

File:Phall-O-meter', Intersex Society of North Wellcome L0031936.jpg satirizes clinical assessments of appropriate clitoris and penis length at birth, and the definition of ambiguous genitalia. It is based on research published by Suzanne Kessler.]]

Cases of trauma include the famous John/Joan case, where sexologist John Money claimed successful reassignment from male to female of a 17-month-old boy whose penis was destroyed during circumcision. However, this claim was later shown to be largely false. The subject, David Reimer, later identified as a man.{{cite web |last=Colapinto |first=John |author-link=John Colapinto|title=Why did David Reimer commit suicide? |website=Slate Magazine |date=3 June 2004 |url=https://slate.com/technology/2004/06/why-did-david-reimer-commit-suicide.html |access-date=20 March 2022 |archive-date=20 March 2022 |archive-url=https://web.archive.org/web/20220320015008/https://slate.com/technology/2004/06/why-did-david-reimer-commit-suicide.html |url-status=live}}

The number of births with ambiguous genitals is in the range of 1 in 2,000 to 1 in 4,500 (0.05% to 0.02%). Typical examples would be an unusually prominent clitoris in an otherwise apparently typical girl, or complete cryptorchidism in an otherwise apparently typical boy. In most of these cases, a sex is tentatively assigned and the parents told that tests will be performed to confirm the apparent sex. Typical tests in this situation might include a pelvic ultrasound to determine the presence of a uterus, a testosterone or 17α-hydroxyprogesterone level, and/or a karyotype. In some of these cases a pediatric endocrinologist is consulted to confirm the tentative sex assignment. The expected assignment is usually confirmed within hours to a few days in these cases.

Some infants are born with enough ambiguity that assignment becomes a more drawn-out process of multiple tests and intensive education of the parents about sexual differentiation. In some of these cases, it is clear that the child will face physical difficulties or social stigma as they grow up, and deciding upon the sex of assignment involves weighing the advantages and disadvantages of either assignment. Intersex activists have criticised "normalising" procedures performed on infants and children, who are unable to provide informed consent.

In European societies, Roman law, post-classical canon law, and later common law, referred to a person's sex as male, female, or hermaphrodite, with legal rights as male or female depending on the characteristics that appeared most dominant. Under Roman law, a hermaphrodite had to be classed as either male or female.{{cite journal |doi=10.1111/1468-0424.00075 |title=The Ideology of the Eunuch Priest |journal=Gender & History |volume=9 |issue=3 |pages=542–559 |year=1997 |last1=Roller |first1=Lynn E.|s2cid=143133728 }} The 12th-century Decretum Gratiani states that "Whether a hermaphrodite may witness a testament, depends on which sex prevails".{{cite web |url=http://geschichte.digitale-sammlungen.de/decretum-gratiani/kapitel/dc_chapter_1_1585 |title=Decretum Gratiani (Kirchenrechtssammlung) |work=Bayerische StaatsBibliothek (Bavarian State Library) |date=5 February 2009 |url-status=live |archive-url=https://web.archive.org/web/20161220084841/http://geschichte.digitale-sammlungen.de/decretum-gratiani/kapitel/dc_chapter_1_1585 |archive-date=20 December 2016}}{{cite book |title=A History of Women and Ordination |last1=Raming |first1=Ida |last2=Macy |first2=Gary |last3=Bernard J |first3=Cook |publisher=Scarecrow Press |date=2004 |page=113}} The foundation of common law, the 16th Century Institutes of the Lawes of England, described how a hermaphrodite could inherit "either as male or female, according to that kind of sexe which doth prevaile."E Coke, The First Part of the Institutes of the Laws of England, Institutes 8.a. (1st Am. Ed. 1812) (16th European ed. 1812).{{Cite journal |volume=41 |last=Greenberg |first=Julie |title=Defining Male and Female: Intersexuality and the Collision Between Law and Biology |journal=Arizona Law Review |date=1999 |ssrn=896307 |pages=277–278}} Legal cases where sex assignment was placed in doubt have been described over the centuries.

With the medicalization of intersex, criteria for assignment have evolved over the decades, as clinical understanding of biological factors and diagnostic tests have improved, as surgical techniques have changed and potential complications have become clearer, and in response to the outcomes and opinions of adults who have grown up with various intersex conditions.

Before the 1950s, assignment was based almost entirely on the appearance of the external genitalia. Although physicians recognized that there were conditions in which the apparent secondary sexual characteristics could develop contrary to the person's sex, and conditions in which the gonadal sex did not match that of the external genitalia, their ability to understand and diagnose such conditions in infancy was too poor to attempt to predict future development in most cases.

In the 1950s, endocrinologists developed a basic understanding of the major intersex conditions such as congenital adrenal hyperplasia (CAH), androgen insensitivity syndrome, and mixed gonadal dysgenesis. The discovery of cortisone allowed survival of infants with severe CAH for the first time. New hormone tests and karyotypes allowed more confident diagnosis in infancy and prediction of future development.

Sex assignment became more than choosing a sex of rearing, but also began to include surgical treatment. Undescended testes could be retrieved. A greatly enlarged clitoris could be amputated to the usual size, but attempts to create a penis were unsuccessful. John Money and others controversially believed that children were more likely to develop a gender identity that matched sex of rearing than might be determined by chromosomes, gonads, or hormones. The resulting medical model was termed the "Optimal gender model".{{Cite book |publisher=Community Affairs References Committee |isbn=978-1-74229-917-4 |last1=Australian Senate |author-link=Australian Senate |last2=Community Affairs References Committee |title=Involuntary or coerced sterilisation of intersex people in Australia |location=Canberra |date=October 2013 |url=http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Involuntary_Sterilisation/Sec_Report/index |url-status=live |archive-url=https://web.archive.org/web/20150923181927/http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Involuntary_Sterilisation/Sec_Report/index |archive-date=23 September 2015}}

Australian government guidelines published in 2013 stated that "individuals should be given the option to select M (male), F (female) or X (Indeterminate/Intersex/Unspecified)" and that government "[d]epartments and agencies will continue to collect sex and/or gender information to inform service delivery, perform their specific function or to contribute to broader government statistical or administrative purposes."{{Cite book |last1=Australia |url=http://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx |title=Australian Government Guidelines on the Recognition of Sex and Gender |last2=Attorney General's Department |date=2013 |archive-url=https://web.archive.org/web/20150701084543/http://www.ag.gov.au/Publications/Pages/AustralianGovernmentGuidelinesontheRecognitionofSexandGender.aspx |archive-date=1 July 2015 |url-status=live}}

A 2014 report for the Dutch Ministry of Justice and Security allowed that while many gender-specific provisions in legislation no longer existed, sex registration, which had been introduced in 1811, was still required for a number of important state functions: family law, pregnancy protections, gender-segregated facilities, affirmative-action policies, and "a limited number of laws and regulations that are specifically aimed at men or women, such as military service." It also found that a majority of civil servants foresaw problems if official gender identifications were removed expanded beyond male and female. It noted that gender "seems to be increasingly experienced as 'sensitive' personal data, but is not yet protected as such by privacy regulations," and advocated for more flexibility and less official requests for gender identification.{{cite web |last1=van den Brink |first1=Marjolein |title=M/F and beyond, Gender registration by the state and the legal position of transgender persons. English summary |date=2014 |url=https://www.wodc.nl/onderzoeksdatabase/2393-de-mogelijheid-en-consequenties-van-het-onbepaald-laten-van-het-geslacht.aspx?cp=44&cs=6796#publicatiegegevens |archive-url=https://web.archive.org/web/20160304045500/https://www.wodc.nl/onderzoeksdatabase/2393-de-mogelijheid-en-consequenties-van-het-onbepaald-laten-van-het-geslacht.aspx?cp=44&cs=6796#publicatiegegevens |publisher=Ministerie van Veiligheid & Justitie |archive-date=4 March 2016 |last2=Tigchelaar |first2=Jet |url-status=live}}

In 2015, Canadian activists petitioned the British Columbia Human Rights Tribunal to force the government to stop recording the sex of newborns on birth certificates in order to avoid what complainants called "misgendered birth certificates" which they asserted were harmful to transgender people.{{Cite web |last=Chan |first=Emily |date=26 May 2015 |title=Get gender off birth certificates, B.C. activists argue |url=http://www.ctvnews.ca/canada/get-gender-off-birth-certificates-b-c-activists-argue-1.2391604 |url-status=live |archive-url=https://web.archive.org/web/20151118053446/http://www.ctvnews.ca/canada/get-gender-off-birth-certificates-b-c-activists-argue-1.2391604 |archive-date=18 November 2015 |access-date=1 January 2016 |work=CTV News}} In 2021, Canada changed the "sex" designation on birth certificates to "sex at birth" in order to reflect that a small number of Canadians subsequently change their gender.{{Cite web |last=Government of Canada |first=Statistics Canada |date=2023-12-12 |title=Sex at Birth of Person Reference Guide |url=https://www.statcan.gc.ca/en/concepts/dds/sbp |access-date=2025-04-17 |website=www.statcan.gc.ca}}

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