Intersex: A lesson in biology, identity and culture

“It’s fun helping people make connections and think of things in new ways,” says neuroscientist Sara Freeman, who won a Crystal Apple teaching award for her class on intersexuality.

By Carol Clark

As a little girl growing up in Atlanta, Sara Freeman says she was a tomboy, preferring to play in the dirt than with dolls. “I dealt with the psychological issue of not behaving like a feminine ideal,” she recalls, “but I don’t think most people ever feel like a perfect version of their sexual assignment.”

She went on to major in biology at the University of Virginia, where she developed an interest in reproductive endocrinology. Freeman is now on the brink of receiving a PhD in neuroscience from Emory, focused on the evolution of behavior, especially in relation to hormones. Her thesis involves the oxytocin system and the social attachment of mammals, drawing from her work in the lab of behavioral neuroscientist Larry Young.

“I find it fascinating that a chemical like a hormone can have such a big influence on an organism’s social interactions,” says Freeman, who loves teaching as much as research.

Last fall, Freeman taught an undergraduate class that she developed called “Intersex: Biology and Gender.”

The seed for the class was planted in 2010, when Freeman watched a short documentary called “One in 2,000” by Fanlight Productions. The film takes its name from the number of people born in the United States who have a variation in sex characteristics that defies the common biological parameters of male or female. “Intersex” is an umbrella term used to describe the phenomenon.

Click here to watch a documentary called "XXXY" by the Intersex Society of North America.

“One of the most surprising things to me about the movie was learning the prevalence and variety of intersex conditions,” Freeman recalls. “All these different names of different diagnoses floated across the screen, and I only recognized four out of about 25 of them. I thought, ‘This is ridiculous. I’m trained in reproductive biology.’”

In an extreme intersex case, a baby may have such ambiguous genitals that the parents and doctors wonder if the child is a boy or a girl.

Other intersex cases may have no overt features. Someone with complete androgen insensitivity syndrome (CAIS), for instance, may look and feel like a female although she has a male XY chromosome pair instead of the usual female XX. The body of a person with CAIS does not respond to the steroid hormone that stimulates the development of male characteristics, despite functional testes hidden in the abdomen.

A child with Klinefelter’s syndrome also may not exhibit any evidence that he has the standard male XY chromosome pair, plus an extra X chromosome. During puberty, however, he may develop slightly enlarged breasts, or bigger hips than usual for a male.

During the 1950s, some members of the medical community began to “fix” the problem of overt sexual ambiguity in babies by making them appear either fully male or female through surgery or hormonal treatments. Some physicians counseled against telling these children about their birth condition, because it could cause them mental trauma.

“Generations of people who were operated on right after they were born had no idea what happened to them,” Freeman says. “But in recent years, intersex people have started to come out and talk about their experiences.”

Some of them never fully identified with the sex category that had been arbitrarily “assigned” to them. Some also bear scars from repeated surgeries that have reduced their sexual sensation.

A growing movement calls for gender identity to be left up to intersex individuals to decide as they get older. “Today, we have a lot more information and advocacy about intersex,” Freeman says, “but some doctors still have the attitude of, let’s fix it and not talk about it.”

The complexities of intersex issues stuck in Freeman’s mind. Later, she took a course on teaching undergraduate science from Pat Marsteller, director of Emory’s Center for Science Education, and she received a Dean’s Teaching Fellowship, giving her the chance to design a course of her own.

Her resulting class on intersex is geared to upper-level undergraduates and is cross-listed in Biology, Sociology and Women’s, Gender and Sexuality Studies. “The idea was to bridge science and the humanities, so students from both worlds can come together and learn from each other,” Freeman says.

She also drew from the knowledge of Emory graduate students and faculty from both worlds to develop the course. Eight of these specialists served as guest instructors for the class, giving their perspectives from neuroscience, women’s, gender and sexuality studies, psychology and pediatric endocrinology. And a local intersexed individual came and spoke, to give the class a personal perspective.

The class delved into social and scientific history, questions of ethics and the nuances of semantics. For instance, while the medical community refers to intersex conditions as “disorders of sexual development,” many intersexed individuals do not feel like they have a disorder.

The students discussed theories around the ideas of disability and normalcy. What does normal mean? And what constitutes a normal male and a normal female?

“College is a coming-of-age time,” Freeman says. “I want students to evaluate the social pressures they experience on a day-to-day basis as they form their own identities, and to learn not to judge others.”

Click here to play the "Meiosis Game."

To help teach the complex biology underlying human sexuality, Freeman enlisted the help of Matt Gilbert, an instructor at the Art Institute of Atlanta who is also a web developer and graphic designer. Freeman and Gilbert worked together to develop two online, interactive sites that turn biological processes into a game-like format.

The “Meiosis Game” takes a player through the cellular division process that results in sperm and egg cells. By clicking through the long chain of steps of sex chromosomal sorting involved during meiosis, students see how natural variations in that process can result in an embryo with sex chromosomes other than the expected XX or XY.

The “Steroidogenesis Game” shows how steroid hormones, like estrogen and testosterone, are synthesized from cholesterol by enzymes. Players start with a molecule of cholesterol and instructions to create a target hormone. They then click on different available enzymes to see how applying each one changes the structure of the molecule. As they make their way through the enzymatic pathways, players see how the absence of any one enzyme may prohibit them from reaching the end goal of creating a particular hormone.

Click here to play the "Steroidogenesis Game."

The tactile, visual, step-by-step “games” serve as a good introduction to complicated biological concepts, while also helping students review material and prepare for tests.

“It’s fun helping people make connections and think of things in new ways,” Freeman says. “The varieties of body and mind that the human species is capable of are beautiful and something to be celebrated. The concept of what is male and what is female shouldn’t be expected to fit into narrow categories.”

The entire class of Freeman’s first group of students nominated her for Emory’s coveted Crystal Apple award for excellence in teaching. A Crystal Apple category didn’t exist for graduate students, but the awards committee created one for Freeman, due to popular demand.

“It meant a lot to me, to get that kind of recognition from my students,” Freeman says, adding that she also learned a lot. “Delving into the humanities side helped me become more aware of the biases you sometimes find in science. It also helped me become a better communicator and be more aware of how easy it is to spread misconceptions.”

Related:
Why do we stare at people who are different?
The science of love
An interview with Sara Freeman on Emory's Neuroethics Blog