There is a lot of mystery and confusion surrounding intersex people, born with characteristics that vary from what is considered typical for female or male bodies, in the Middle East and North Africa (MENA) region. The region’s societies generally do not tolerate any identity outside the binary, even when it is biological. Intersex people are forced to hide their identity due to a general lack of awareness and misunderstanding surrounding intersexuality, as well as heavy stigmatization of the intersex identity. As a result, many view intersex people as a cultural taboo since they do not fit the traditional binary system and its fixed gender roles. Even if a person is intersex, they are still expected to be assigned a binary gender identity that they must adhere to, in order to avoid being stigmatized. Some treat having an intersex child as a bad omen and a test from God, who gave them this hardship as a test to their faith. Most of the region’s civil codes rely on promoting a binary understanding of society, without much room to recognize intersex people as a separate third sex.
The Arabic terminology to describe intersex people still relies on outdated tropes: derogatory terms such as khuntha are still widespread, while the more politically correct terms such as thanawy al–gans or beyny al-gans are hardly used outside progressive circles. The general public and some national and international media mix being intersex with being transgender as the term “sex change” is used as a catch-all term that would describe any person who would change their “sex” in adulthood. In addition, the stigma and discrimination against transgender people can spill over to intersex people who may wish to undergo surgeries in adulthood, as they are treated the same socially.
There are no statistics on the number of intersex people in the MENA region, but the global rates put this number at up to 1.7 percent of the general population. An Egyptian study from 2017 estimates the incidence of newborns “with ambiguous genitalia” to be in the range of 1/5,000 and 1/3,000 of live births. Studies from Iraq, Lebanon, and Egypt indicate that most intersex people make it at least into puberty before being diagnosed as intersex. However, once diagnosed, regardless of age, medical policies are designed to reflect the binary imposed by society and religion, and encourage intersex people to undergo surgery to make them fit, even when not necessary.
All of this leads to intersex data and personal experience being hard to document and gather, which makes studying the issue in the region a difficult task.
In this environment, intersex people are made invisible in the community. Most may not even know of their identity, and those who know may keep it hidden and assume a gender role to avoid social challenges. All of this leads to intersex data and personal experience being hard to document and gather, which makes studying the issue in the region a difficult task.
Socio-medical policy or the lack of one
While intersex activism has been gaining more attraction globally, pathologizing intersex identities is still common. The current medical discourse promotes unnecessary medical interventions on healthy intersex bodies with the sole purpose of making them fit into the binary. Intersex activists oppose this medical practice, dubbing it intersex genital mutilation (IGM), and compare it to female genital mutilation, as both practices violate people’s bodily autonomy, have no medical necessity, and can cause long-lasting medical problems. Only six countries, all European, currently ban IGM on children, while consenting adults can undergo surgeries if they wish.
In the MENA region, medical policy on intersex people is not universal. It often only exists verbally, is vague, and leaves much discretion for parents and doctors to decide which sex the intersex infant should be assigned. In fact, intersexuality is treated as a birth defect that should be treated upon birth. Surgeries happen even though medical staff often lack the necessary resources, training, and education to deal with intersex people. While medical tests such as chromosome mapping and the examination of reproductive organs are needed to make an accurate decision on the infant’s binary sex, countries like Egypt, Lebanon, and Iraq lack the proper resources to conduct such tests. Oftentimes, doctors advise parents on next steps based on an external examination of the genitals without conducting further tests. This means that infants might be assigned a sex that is not reflective of their internal reproductive organs or chromosomes, which can subsequently lead to significant health problems in the future, including bad mental health, sexual health problems, and reproductive issues.
“Doctors often try to make the best out of the little resources they have: often, the required tests are not available to them, and they advise parents after only externally examining the infant’s genitals,” says Bakhan Qadir, a gender specialist based in Erbil, in Iraq’s Kurdistan region. “Parents have the ultimate decisive power when it comes to determining the sex of the infant, and the doctor’s decisions are only considered to be advisory,” adds Qadir.
Other countries in the region such as Saudi Arabia and Morocco seem to allocate more resources toward intersex healthcare. Saudi Arabia has the only medical center in the region specialized in intersex surgeries, having performed 2,000 surgeries on intersex people in the past 38 years. In Morocco, tests are considered the standard, and medical outcomes are decided based on test results. “When an infant is diagnosed with intersexuality, several tests are run, including the examination of internal organs, chromosome panels, and hormonal mapping. The results are then submitted to a medical committee in the hospital which decides which sex the infant will be assigned, if any at all, as sometimes it is hard to determine the sex of the infant. It is better to wait until puberty to determine which sex characteristics the infant will grow to have,” says Soufiane Hennani, a biologist and queer activist based in Dar El Beida in Morocco.
Leaving the final decision to parents opens the door to social bias, as male children are often more celebrated than female children for various religious and societal reasons: males possess more bodily autonomy in society, Islamic rules of inheritance favor them, females are still considered as a possible source of shame, and the financial prospect of males versus that of females is considered brighter, among others. Parents often do not tell their children that they are intersex. This, coupled with inadequate medical record-keeping in the region, means that most of the time, intersex people who undergo surgeries as infants will not become aware of their actual sex identity unless they suffer from a medical problem that would require tests which would then reveal that information to them. Furthermore, parents who may wish to wait for their children to undergo the surgeries later are pressured by both medical staff and family members to ‘fix’ their child as soon as possible. However, early diagnosis of intersex people is still challenging, due to the lack of training for medical staff and at-home births which are widespread in the region. According to a study at Cairo University Hospital in Egypt, only 16 of the 314 documented intersex cases at the hospital between 1986 and 2000 were diagnosed at birth while most were diagnosed after puberty. Another study from 2017 on intersex cases dealt with at Cairo’s National Research Center supports this finding. Many may spend their entire life without ever knowing that they are actually intersex.
Finding out that a person is intersex later in life can be very stressful, as MENA societies have strict gender roles, meaning that the person may have already developed a fixed gender identity, reflective of the sex they were assigned at birth.
Finding out that a person is intersex later in life can be very stressful, as MENA societies have strict gender roles, meaning that the person may have already developed a fixed gender identity, reflective of the sex they were assigned at birth. A 2015 study from Iraq found that there were 243 cases of adults living with intersex characteristics in the country, most of whom expressed distress and concerns over undergoing surgeries as adults, as they suffered from shame and stigma due to the society’s lack of awareness about intersexuality. In 2018, an Iraqi citizen publicly came out as intersex—marking them as the first person to do so in the country—and shared their experiences undergoing surgeries.
Adam from Egypt shared his experience with TIMEP on being raised as a female and later diagnosed with intersexuality when he reached puberty and began showing masculine characteristics. “Doctors advised my family and I to move out of our village after I was diagnosed as being intersex, but I did not want to burden my family and told them we could stay. I regret this decision now, as I became the talk of the village as if being intersex was a crime. To this day, I am still taunted by people in the village.” He adds, “people tried to comfort my parents, saying at least I would be a man now, which is better than being a woman in our society.” Like many other people assigned female at birth, Adam underwent female genital mutilation (FGM) at a young age. The doctor who did the harmful procedure did not notice anything wrong with Adam’s genitals. FGM is especially harmful to intersex people misidentified as female, as it makes it harder to reconstruct the male genitals for intersex people who may want to undergo surgeries later on in life.
Sometimes, I wonder if it was best not to undergo the surgeries and live as intersex, but knowing Egyptian society and how it functions, I know this is not even a possibility.Adam*
The quality of the medical care provided to intersex people is questionable as pointed out by a Lebanese study published in 2022. In addition to the lack of training, doctors’ pride can be a factor in conducting surgeries they have not been trained for, leading to bad outcomes. Adam voiced his frustrations when talking about his experience with surgeries: “I underwent five surgeries before just becoming fed up with being under a surgeon’s knife for the rest of my life. The results of the surgeries are not the best. Sometimes, I wonder if it was best not to undergo the surgeries and live as intersex, but knowing Egyptian society and how it functions, I know this is not even a possibility.”
It is important to note that in official medical policies across the region, the term “sex correction” describes medical interventions for intersex people. In contrast, “sex change” is the term used for transgender people. There is a differentiation between the two groups, as most policies only allow medical interventions for intersex people, not transgender people. However, the general public and some media do not understand the difference between those two terms. Foreign media often report on news related to intersex medical care using terms such as “sex reassignment surgeries,” which confuses the Western audience, as such a term is often used to describe surgeries for transgender people. Thus, it is essential to use the correct local terminology, “sex correction,” when reporting on medical policy for intersex people.
Legal recognition: third sex or new binary identity
Globally, there is a push to recognize intersex people as a third gender in official documents and not to register them as female or male, as it adds to their invisibility. However, in a region where Islam is the dominant source of law, culture, and social
standards, it seems nearly impossible to see such a legal change in the near future. Islamic jurisprudence emphasizes the binary of two sexes as the foundation of society, as rules of inheritance, marriage, divorce, work, and travel are gender-based. Thus, any identity that exists outside that binary is not accepted by some Islamic jurists. To contest the existence of intersexuality, some Islamic jurists have deemed it a duty for intersex people to undergo surgeries to “reveal what is hidden,” i.e. which binary sex they are.
The process to change one’s papers in the region is hard and restrictive, primarily to keep transgender people from accessing it.
Intersex people who may want to live a binary life after undergoing surgeries can face numerous challenges. The legal systems in the region are not equipped to deal with document changes for intersex people: the process to change one’s papers in the region is hard and restrictive, primarily to keep transgender people from accessing it. While intersex people are allowed to change their documents if they wish to do so, the process is riddled with obstacles, as they must show proof of their intersexuality and undergo further examination by judicial authorities. The judicial process to change one’s documents can be costly, lengthy, and very stressful for intersex people who live in a legal limbo with papers that do not match their sex identity. Currently, only two countries have specific provisions in their civil status code that would allow intersex people to change their documents without undergoing the lengthy judicial process: Saudi Arabia’s Article 39 of the Civil Status Code and Morocco’s Article 28 of the Civil Status Law, passed only in 2021.
Bumpy ride to reform
While recognizing the intersex identity in law and policy in the MENA region can seem like a far-fetched idea, there are some arguments to be made to at least have some basis for such recognition in the future.
While banning intersex genital mutilation seems to be an unthinkable request to demand from policymakers in the region, there is an argument to be made for it, especially in light of how under-resourced and ill-prepared medical facilities are to handle intersex surgeries. Medical staff and facilities must be provided with resources to treat intersex infants beyond just performing IGM, as the practice has been scientifically proven to be harmful. Medical facilities and staff should also be provided with the resources and training to allow successful intersex-related surgeries for consenting adults. In addition, intersex people who may wish to live a binary life should be allowed an accessible and easy method to change their papers without going through judicial barriers.
Global intersex activists have criticized the inclusion of intersex rights under the umbrella of LGBT as it leads to further invisibility and misrepresentation of intersex issues by people who are not intersex. In the MENA region, this issue is more prevalent, as intersex issues are just grouped with transgender issues despite the different needs and challenges, as well as different policies and religious opinions on both issues. Intersex activism in the region is lagging, not only due to this misrepresentation under the LGBT umbrella but also because intersex people are often unaware of their identity, and those who are are shamed by society into silence. Thus, it is crucial to examine intersex issues in the region on their merit and not just as an extension or a token of LGBT rights, especially as socio-religious views tolerate being intersex more than being LGBT. Informed allyship can be a starting point for establishing intersex activism in the region. Policymakers, religious leaders, and medical staff can play a crucial role in paving the way for intersex people to be more public about their identities by raising social awareness and acceptance of the issue. As global LGBT actors and NGOs look into expanding intersex activism into the MENA region, they must keep the region’s context in mind and avoid reproducing Western activism on the issue without contextualizing it.
Nora Noralla is an Egyptian human rights researcher and consultant focusing mainly on issues of sexual and bodily freedoms as well as Islamic Sharia and human rights in the MENA region.