Gender identity

GENDER IDENTITY WITH THE WRONG NAME

National Institute of Legal Medicine and Forensic Sciences, Special Edition

Gina Cabeza Monroy

Medical specialist in Psychiatry.

National Institute of Legal Medicine and Forensic Sciences.

- Office, Bogotá -

-Bogotá, D.C. - Colombia.

Correspondence to:

Gina Cabeza Monroy.

Forensic Psychiatry and Psychology Group.

National Institute of Legal Medicine and Forensic Sciences.

Email: gicamo16@hotmail.com

SUMMARY

This is the case of a six-year-old schoolchild —identified as J— who was born with ambiguous external genitalia. Upon medical recommendation, the child was registered as male by the parents; however, further testing (diagnostic imaging and karyotyping) showed that the child was biologically female. Based on this, the parents started the judicial process to change their child’s name, and the judge ordered a forensic psychiatric evaluation to determine the child’s true sex1. When the forensic study concluded that the child’s sex was female, the result was transmitted to government authorities and the name was corrected in the child’s civil registry.

Keywords: Gender identity; Forensic psychiatry; Sexual behavior; Genital abnormalities.

INTRODUCTION

When assigning gender to a child with ambiguous genitalia there is still a controversy: while some argue that the legal sex of a newborn with phenotypically ambiguous genitalia should be assigned according to the degree of virilization (1), i.e. the size of the penis, and others state that maintain that gender identity is prenatally imprinted by unknown mechanisms and that it should, therefore, not be assigned purely on anatomical morphology, but rather through a chromosomal and gonadal analysis in children under two years of age (2,3) and an evaluation of gender identity in older children. Other authors take this debate further and consider that the gender identity assumed by a person is more important than the one biologically assigned, whether chromosomal or gonadal aspects are considered, and that gender identity, thus, should be determined before opting for any surgical intervention. The lack of long-term studies further fuels this controversy (6).

In order to assign sex in humans it is necessary to take into account multiple concepts (Table 1). Any discrepancy in gender assignment can cause problems related to sexual and gender identity.

Type of designation	Main characteristic	Time of designation
Chromosome gender	Designated by chromosomes.	At conception. (7)
Gonadal gender	Presence of gonads. Occasional presence of an intermediate state, whereby both female and male gonads are present (ovotestis).	During gestation. (7)
Morphological gender	Presence or absence of a penis	At birth. (7)
Legal gender	Civil registry.	At the civil registry.
Gender identity	Identifying as a man or a woman.	Between 18 months and three years. (8, 9)
Sexual orientation	Attraction or sexual leaning towards men, women or both sexes.	Controversial. (9)

Table 1. Definitions of gender assignment.

Source: I. Based on Oliva et al. (10).

Until june 2015 in Colombia, name changes in the civil registry were only permitted once and legal sex was impossible to change (11). With the issuing of Decree 1227 in 2015 (12), now those of legal age can change their name and sex in their civil registry by public deed, but minors are still submitted to a forensic psychiatric evaluation to establish a definitive gender identity to allow for a legal name change.

In 1998, a mother requested sex reassignment surgery for her daughter under a guardianship petition. However, the Constitutional Court declared a moratorium on the surgery of the minor until she could give her consent and ordered to health institutions and to the Instituto Colombiano de Bienestar Familiar (Colombian Institute of Child Welfare) to establish an interdisciplinary team of doctors, psychotherapists and social workers to provide medical and psychological care to the minor and establish if said minor had sufficient autonomy to provide informed consent for the surgery and hormone treatments. Despite the controversy of this decision, by ruling that children and adolescents can make health decisions before reaching legal age, the Court recognized the medical, psychological and social difficulties in these cases as well as the unpredictability and complexity of the legal consequences, leading to a follow-up by interdisciplinary teams and proposing a detailed evaluation of each individual case (13).

With this in mind, it is presented the case of a school child that was born with ambiguous external genitalia who was legally registered as male by the family, but now, six years later, the child’s family has requested a name change to one corresponding to the femenin gender in a correction process at the civil registry.

CASE DESCRIPTION

After studying the brief and following the guidelines of the Protocol for Basic Evaluation in Forensic Psychiatry and Psychology (14) of the National Institute of Legal Medicine and Forensic Sciences, an analysis was conducted. Informed consent of the mother and child were taken, along with prints of their right index fingers. Later, an interview was conducted with the minor for forensic psychiatric purposes, along with a mental examination and the Draw-a-Person test.

Study of the brief

The following aspects are highlighted:

A. May 2008. The summary of the clinical history on record states: “patient of female sex that presents with an enzymatic 21-hydroxylase deficiency confirmed by clinical history as well as by hormonal and cytogenetic testing. Must continue with medical and surgical treatment, a new evaluation from urology is requested”.

B. October 2006. A copy of the abdominal ultrasound states: “image that suggests the presence of a uterus”.

C. November 2010. A report from the forensic clinic at the National Institute of Legal Medicine and Forensic Sciences shows that: “[…] a 21-hydroxylase deficiency constitutes the most common form of congenital adrenal hyperplasia, which conditions the virilization of external genitalia in women. [...] a minor with female karyotype (XX) and imagining studies suggest the presence of a uterus, while the physical exam reveals ambiguous external genitalia”.

Clinical history: summary of the interview and psychiatric evaluation

A. Family history: according to the information contributed by the mother, the primary family nucleus is composed of the mother and two children (the parents were separated several years ago). J is the younger child. The father is 40 years old and the mother is 26.

B. Personal history: The pregnancy was carried to term through vaginal birth with no complications. The child started sitting up at 6 months of age, walking and talking at 12 months of age and entered preschool at 4 years of age. The mother commented: “I made the mistake of overprotecting her and I didn’t want to send her to school since I was afraid they would mistreat her. She hasn’t seen a speech therapist, occupational therapist nor a psychologist [...] when you ask her something she thinks about it a lot, three months after starting school she would pee herself, I think she was scared, she wouldn’t tell anyone she had to go to the bathroom for fear that someone would see her, but now no, so I think I overprotected her [...] when I take a bath with her and she asks me why you are that way and why I have this (pointing to the genital area) and I explained to her that she had to get surgery so that we would be the same [...] academically she is doing well, she’s very clever and often finishes her work before her classmates”.

To describe herself J stated: “I want people to call me Valeria [...] I have a friend whose name is Juan David [...] we play hide and seek [...] I like boots [...] because they have flowers on them, they’re pretty and I have a doll, I like dolls [...] I don’t like motorcycles, motorcycles are for boys”.

To answer the question “In what way are boys and girls different?” J stated: “Juan David is different from me in his hands and shoes [...] my brother is different because he is big and has brown skin, and I am white [...] Bryan is a man, women have a “vagiga” (points to her belly button) [...] this is called [...] (pauses to think) vagina [...] boys run around and girls play hide and seek [...] if boys hit me, I don’t hit back, I tell the teacher on them”.

The mother of the child: “When she was born and they told me to take a good look at him and they took him away, I was looking to see if he was fine [...] I asked about my son and they talked to the doctor first and they said that they had her upstairs because she had ambiguous genitalia and a hormone problem above the kidneys. They didn’t know what the sex was and that she should be kept in hospital to examine her and they were asking why she was born that way and they were going to test the karyotype. They released me and I was going to lactate her and they didn’t do the karyotype test and the doctor told me that the baby was a boy and that I should register her as such at the hospital. We started medical testing and we went to the appointment and we started the process with ultrasounds, they told me that they needed to test the karyotype but the POS (Colombian obligatory health insurance plan) doesn’t cover this so they made an appointment with an endocrinologist, a urologist and a geneticist; the latter told me that she was fine, but in addition to this problem she could also have other problems, so after hearing this I felt devastated, because if I didn’t take care of her, they said, she could die. In urology they said that they could do the surgery with the karyotype but they wouldn’t do it because of her weight and that she would have to be on medication for all of her life and continue with check-ups [...] I started the request under legal protection and at 8 months they tested the karyotype. It turned out that yes, she was a girl and that they would have to do vaginal reconstruction and get surgery but the urologists didn’t want this [...] within a year she had seizures, her potassium and sodium levels were low and they put her on a diet. For me, my baby was a girl, I always knew [...] I would dress her normally, neither a boy nor as a girl, but from the moment of the karyotype test I started dressing her as a girl and the family gave her a name and we started calling her Valeria and she has been called this way ever since she can understand [...] Her father lost his job but occasionally had insurance, but the surgery still didn’t happen, they told me that it was going to take place in a group belonging to the hospital of the Misericordia, but they didn’t authorize it. Her father was once again unemployed and the girl was uninsured for 3 years and the process for the surgery stopped [...] I saw her as my girl, but she had some rough behavior [...] the teacher says she is strange because she chases the boys”.

C. Specific background: negative for any surgical, allergic, toxic, traumatic, family and psychiatric conditions. As for pathology, she presented with adrenal hyperplasia and an alpha-hydroxylase enzyme deficiency.

Mental examination

Important note: a physical examination was not conducted since this is not part of the psychiatric-forensic expertise.

J entered the exam room by herself, accompanied by her mother. Her apparent age was chronologically consistent, and she was wearing a blouse and skirt and introduced herself as “Valeria”. During the interview, it is worth noting that eye contact with the interviewer was intermittent. She seemed quiet and calm and moved around the exam room with delicate gestures. Her mood appeared to be normal, non-depressed and regulated, and her thinking, a bit slowed, tended towards concretism — findings that are consistent with her chronological age. She displayed prolonged question-answer time with no delusional ideas; her characteristics can be summarized as follows:

• Language: sharp and low tone of voice.

• Sensory-perceptive aspect: no change.

• Sensory aspect: oriented in person and space, partially disoriented in time.

• Attention: normal attention span.

• Intelligence: average.

• Judgment of reality: preserved.

Draw-a-Person test

The child viewed herself as “Valeria”, which was corroborated by the Draw-a-Person test in which she drew herself as a girl and wrote the name “Valeria” to designate herself.

RESULTS

Forensic Psychiatric Analysis of the case:

J is a six-year-old girl who comes from a low socio-economic background and single-parent home described by her mother as functional. According to the facts that were gathered, she has had an adequate psychomotor development and adaptation to her family and social environment that is fitting to her social and cultural conditions. Given that the baby was born with ambiguous external genitalia but with the presence of a penis, the mother, upon medical recommendation, registered the sex as male. However, at 8 months of age, evidence was found in an abdominal ultrasound of internal female genitalia; the geneticist proved the female sex with a karyotype test and she was diagnosed with adrenal hyperplasia with a 21-hydroxylase deficiency; this deficiency is a congenital disease of genetic origin in which an enzyme of the adrenal gland is not produced, which causes adrenal hyperplasia.

The excessive production of androgenic hormones in a female fetus causes the growth of the clitoris, which can sometimes be mistaken for a penis, though genetically the fetus is female with the presence of a uterus and ovaries (15). This condition must be detected early (7), so as to avoid a mistaken sex assignment and to initiate treatment as soon as possible, since affected individuals often present with premature sexual development, acceleration of skeletal maturity (with the corresponding low height) and problems with electrolytes in the blood. Medical literature recommends to raise and treat a newborn child with 21-hydroxylase deficiency as a normal girl and to carry out corrective surgery as soon as possible to avoid problems with body image (15).

However, other authors consider it necessary to wait to identify gender identity before proceeding with surgical intervention (6). In the reported case, the delay in corrective genital surgery has generated body identity problems, since she has shown confusion about how her body is “different” from her mother’s, as evidenced by the interview.

Despite the family and child not initially receiving the treatment necessary for the disease and financial difficulties with the health care system, the mother states that once the result of the karyotype was announced, before reaching a year of age, her nuclear and extended family started to call her “Valeria” and the mother started to dress her in feminine clothing. During the exam, J presented with behaviour socially considered as feminine — delicateness in her way of talking and moving— and recognized the differences between boys and girls, although she only identified the external ones. It is important to note that the girl considered herself as “Valeria”, which was corroborated through the projective Draw-a-Person test in which the child drew herself as a girl and gave herself the name “Valeria”. Based on everything described so far, this suggests that the person identified as J is of female gender identity.

Lastly, it is important to add that at the time of forensic evaluation, the child had gone more than three years without medical treatment for her condition, which is why the medical, surgical and psychological treatments were deemed urgent and necessary. It was also suggested that the mother attend a support group for parents with children who have 21-hydroxylase deficiency to receive the adequate psychological treatment for her anxiety in dealing with her daughter’s condition.

DISCUSSION

According to international medical literature, gender identity is a psychological construct and not merely a consequence of biological factors (16). As such, it is the result of complex mental processes which are developed in the first few years of life and are established around 3 years of age (17). In this particular case, gender identity was consistent with the biological sex and social assignment of gender, though in some exceptional cases, the gender identity is not concordant. In other words, the individual has the perception of “being in the wrong body”, and forensic psychiatry is needed to establish in the mind of the individual what gender identity they identify with, from the perspective of the individual’s own perception of self, regardless of external characteristics and social influence. It is a meticulous and persistent search of the psychiatric expert within the mind of an individual to determine senses of masculinity or femininity.

In children, this legal evaluation begins by examining the name of the child—which on occasion is also ambiguous, for example “Charlie”, “Mikel” or “Yin”. Then, the evaluation looks for a feeling of acceptance towards this name (such as pride), or on the contrary, feelings of inadequacy, rejection, shame or rage. Later, the behavioral patterns of the child’s nuclear family, the relationships with parents and siblings, play patterns, interactions with peers (classmates or neighbors of the same age), how the child exercises gender roles (their role towards others), perception of self and surroundings, and personal autonomy. Finally, body image (and any of its distortions) are evaluated. In the mental examination, behavior is analyzed for the way in which the patient enters the exam room, the attitude towards the interviewer, delicate or rough movements, ways of greeting and tone of voice, among others.

After receiving the results of the psychiatric review, the judicial authorities are able to approve the name change in the civil registry. This allows the individual to adapt his or her name to the gender identity and then adapt his or her body to the mind (and not the other way around), avoiding irreparable damages to the psyche (18).

While in Argentina the change of name and sex is a simple administrative procedure that does not require medical or psychiatric diagnosis and has been permitted since 2012 (19), in Colombia it has only been possible since June 2015 for children and adults to change their name and legal sex. It is highly recommendable that when children are born with ambiguous genitalia an exception to the law be considered, authorizing the name change and respecting his or her rights, based always on a case-by-case evaluation of the true gender identity, and focusing later on legal sex when legal age is reached and the individual has the capacity to decide for him or herself.

Keeping in mind the forensic and legal rather than therapeutic nature of the study, this author does not establish a relationship with these individuals to know their subjective experience, but rather to resolve the case at the request of authorities.

ACKNOWLEDGEMENTS

Thank you to doctors Iván Perea and Adriana Bautista of the Forensic Psychiatry and Psychology Group at the National Institute of Legal Medicine and Forensic Science for their valuable collaboration in the review of this article.

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